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North Carolina Study Commission on Aging : report to the ... General Assembly of North Carolina ... Session

North Carolina Study Commission on Aging : report to the... General Assembly of North Carolina... session

NORTH CAROLINA
STUDY COMMISSION ON AGING
REPORT TO THE
GOVERNOR AND THE 2004 REGULAR SESSION OF THE
2003 GENERAL ASSEMBLY
A LIMITED NUMBER OF COPIES OF THIS REPORT IS AVAILABLE
FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY.
ROOMS 2126, 2226
STATE LEGISLATIVE BUILDING
RALEIGH, NORTH CAROLINA 27611
TELEPHONE: (919) 733-7778
OR
ROOM 500
LEGISLATIVE OFFICE BUILDING
RALEIGH, NORTH CAROLINA 27603-5925
TELEPHONE: (919) 733-9390
North Carolina
Study Commission On Aging
April 27, 2004
To: Governor Michael Easley
Lieutenant Governor Beverly Perdue, President of the North Carolina Senate
Senator Marc Basnight, President Pro Tempore of the North Carolina Senate
Representative James Black, Speaker of the North Carolina House of Representatives
Representative Richard Morgan, Speaker of the North Carolina House of Representatives
Members of the 2003 General Assembly, Regular Session 2004
Attached is a report from the North Carolina Study Commission on Aging submitted to you
pursuant to North Carolina General Statute §120-187. The North Carolina Study Commission on
Aging presents to you findings and recommendations based on study conducted after the
adjournment of the 2003 Regular Session of the 2003 General Assembly. Proposed legislation is
contained within this report.
Respectfully submitted,
___________________________ ___________________________
Senator A.B. Swindell, IV Representative Debbie A. Clary
Co-Chair Co-Chair
___________________________
Representative Edd Nye
Co-Chair
i
North Carolina Study Commission On Aging
2004 Membership List
President Pro Tempore's Appointments Speakers' Appointments
Senator Albin B. Swindell IV, Co-Chair Representative Debbie A. Clary, Co-Chair
Senator Austin M. Allran Representative Edd Nye, Co-Chair
Senator Charlie S. Dannelly Representative David R. Lewis
Senator Tony P. Moore Representative Jennifer Weiss
Senator Joe Sam Queen Representative William Eugene Wilson
Mr. Brad Allen Ms. Katherine Fox Price
Ms. Jan Elliot Ms. Florence Gray Soltys
Mr. Sam Marsh Ms. Linda Howard
Ex Officio:
Mr. Jackie Sheppard, Assistant Secretary,
Long Term Care and Family Services,
Department of Health and Human Services
Clerk:
Jo Bobbitt
919/733-5477
Staff:
Theresa Matula
Dianna Jessup
Research Division
919/733-2578
Susan Morgan
Fiscal Research Division
919/733-4910
ii
North Carolina Study Commission on Aging 1
Report to the Governor and the 2004 Session of the 2003 General Assembly
TABLE OF CONTENTS
LETTER OF TRANSMITTAL ................................................................................................. i
MEMBERSHIP LIST ................................................................................................................ ii
PREFACE ................................................................................................................................. 4
EXECUTIVE SUMMARY......................................................................................................... 5
OLDER ADULTS IN NORTH CAROLINA: A PROFILE .................................................... 7
COMMISSION PROCEEDINGS.............................................................................................. 11
COMMISSION RECOMMENDATIONS................................................................................. 16
APPENDICES
APPENDIX A ............................................................................................................................. 27
North Carolina Demographics of Aging
APPENDIX B ............................................................................................................................ 31
Commission Recommendations to 2003 General Assembly, 2003 Regular Session
Summary of Substantive Legislation Related to Aging, 2003 Session
Studies and Reports Related to Aging
APPENDIX C ............................................................................................................................ 44
Overview of Aging Services and the State Aging Plan Presentation
APPENDIX D ............................................................................................................................ 48
Guardianship Reform in the Twenty-First Century
APPENDIX E ............................................................................................................................. 53
Tax Treatment of Long-Term Care Insurance in Selected States
Long-Term Care Credits Claimed for TY 2002
AAHP-HIAA State Tax Incentives for Purchase of LTCI
APPENDIX F.............................................................................................................................. 58
Mentally Ill Population in Adult Care Homes In NC
Geriatric Mental Health Specialty Teams Presentation
Geriatric Mental Health Specialty Team Model and Guidelines
APPENDIX G............................................................................................................................. 66
Summary of Presentations by Organizations Representing Older Adults
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 2
APPENDIX H............................................................................................................................. 72
Home and Community Care Block Grant Presentation
Facts about the Home and Community Care Block Grant
Summary of Home and Community Care Block Grant Budgeted Funding
APPENDIX I.............................................................................................................................. 85
Adult Day Services in Brief
Types of Programs and Geographic Location in North Carolina
Staffing Ratios
Adult Day Services Program Closings 2001-2003
Adult Day Services Funding Fact Sheet
APPENDIX J: LEGISLATIVE PROPOSALS ......................................................................... 95
(SWz-32) AN ACT TO REPEAL THE SUNSET ON THE LONG-TERM CARE
INSURANCE TAX CREDIT, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SHz-13) AN ACT TO PROVIDE SUPPORT AND TRAINING FOR LONG-TERM CARE
PROVIDERS CARING FOR RESIDENTS WITH MENTAL ILLNESSES, AS
RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING.
(SHz-16) AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO STUDY ISSUES RELATED TO MENTALLY ILL RESIDENTS IN
LONG-TERM CARE FACILITIES, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SWz-37) AN ACT TO ESTABLISH A PILOT PROGRAM TO CONDUCT NATIONAL
CRIMINAL HISTORY RECORD CHECKS OF PERSONS SEEKING EMPLOYMENT
TO PROVIDE DIRECT CARE IN ADULT CARE HOMES AND CONTRACT
AGENCIES OF ADULT CARE HOMES, AND TO MAKE CONFORMING CHANGES,
AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON
AGING.
(SHz-6) AN ACT TO APPROPRIATE FUNDS FOR SENIOR CENTER DEVELOPMENT
AND OUTREACH, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
(SHz-7) AN ACT TO APPROPRIATE FUNDS FOR SENIOR ADULT HOUSING, AS
RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING.
(SHz-8) AN ACT TO APPROPRIATE FUNDS FOR THE HOME AND COMMUNITY
CARE BLOCK GRANT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
(SWz-34)AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO STUDY WHETHER AN INSTITUTIONAL BIAS EXISTS IN THE
STATE'S MEDICAID PROGRAM, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
North Carolina Study Commission on Aging 3
Report to the Governor and the 2004 Session of the 2003 General Assembly
(SWz-33) AN ACT TO ESTABLISH THE LEGISLATIVE STUDY COMMISSION ON
STATE GUARDIANSHIP LAWS, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SHz-11) AN ACT TO APPROPRIATE FUNDS AND TO REQUIRE THE SOCIAL
SERVICES COMMISSION TO ADOPT A RATE INCREASE FOR ADULT DAY
SERVICES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 4
PREFACE
As outlined in Chapter 120, Article 21 of the North Carolina General Statutes, the North
Carolina Study Commission on Aging is charged with studying and evaluating the existing
system of delivery of State services to older adults and recommending an improved system of
delivery to meet the present and future needs of older adults. The Commission consists of 17
members. Of these members, eight are appointed by the Speaker of the House of
Representatives, eight are appointed by the President Pro Tempore of the Senate, and the
Secretary of the Department of Health and Human Services or the Secretary’s designee serves as
an ex officio, non-voting member.
This report represents the work performed by the North Carolina Study Commission on Aging
from the conclusion of the 2003 Session of the 2003 General Assembly until the convening of
the 2004 Session of the 2003 General Assembly. The Study Commission on Aging met on five
occasions to study a variety of topics concerning older adults including: guardianship, a long-term
care insurance tax credit, caring for the mentally ill in long-term care facilities, prescription
drug assistance, disease management, elder care housing, the long-term care workforce, adult
day services, the Home and Community Care Block Grant, and criminal history record checks of
long-term care employees. During the course of its study, the Commission also heard
presentations by representatives from fourteen (14) organizations advocating on behalf of older
adults in North Carolina.
North Carolina Study Commission on Aging 5
Report to the Governor and the 2004 Session of the 2003 General Assembly
EXECUTIVE SUMMARY
North Carolina General Statutes Chapter 143B, Article 3, Parts 14A. and 14B. establish North
Carolina's Policy Act for the Aging, and Long-Term Care. The principles of the Policy Act for
the Aging are to effectively utilize the resources of the State, to provide a better quality of life for
senior citizens, and to assure older adults the right of choosing where and how they want to live.
The Long-Term Care policy recognizes that traditional caregivers are increasingly employed
outside the home and create a growing demand for improvement and expansion of home and
community-based long-term care services to support and complement the services provided by
informal caregivers. The long-term care policy provides that the public interest would best be
served by a broad array of long-term care services that support persons who need services in the
home or in the community whenever practicable, and that promote individual autonomy, dignity
and choice. The provision also provides that institutional care will continue to be a critical part
of the State's long-term care options and that services should promote individual dignity,
autonomy, and a home-like environment.
The current size of North Carolina's older adult population, and trends indicating that this
segment of the population will increase, indicate the importance of an intense and sustained
focus on the support systems and services that North Carolina has in place for older adults.
Study efforts undertaken during the 2003-2004 interim by the North Carolina Study Commission
on Aging, sought to evaluate the existing system of services to older adults and to recommend
improvements. In response to this study, the North Carolina Study Commission on Aging makes
the following recommendations to the Governor and the 2004 Session of the 2003 General
Assembly:
Recommendation 1
The North Carolina Study Commission on Aging recommends that the General Assembly
repeal the sunset on the Long-Term Care Insurance Tax Credit.
Recommendation 2
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to continue to provide support and
training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams;
and by standardizing criteria across the Teams and tracking utilization and expenditure
data.
Recommendation 3
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to work with long-term care
providers and advocates for the elderly and the mentally ill to study issues related to
mentally ill individuals residing in long-term care facilities.
Recommendation 4
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a pilot program to conduct national criminal history record checks of persons
seeking employment to provide direct care in adult care homes or contract agencies of
adult care homes.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 6
Recommendation 5
The North Carolina Study Commission on Aging recommends that the General Assembly
support Senior Center development and outreach, and restore funding to the 2002 level, by
appropriating $281,000 for the 2004-2005 fiscal year.
Recommendation 6
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used
for independent housing with services.
Recommendation 7
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005
fiscal year.
Recommendation 8
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to study whether the State's
Medicaid Program has a bias that favors support for individuals in institutional settings
over support for individuals living at home; and to recommend ways to alleviate this bias,
if such a bias exists.
Recommendation 9
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a Legislative Study Commission to study State guardianship laws.
Recommendation 10
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate funds and require the Social Services Commission to adopt a rate increase of
no less than five dollars ($5.00) per day for adult day and adult day health services.
North Carolina Study Commission on Aging 7
Report to the Governor and the 2004 Session of the 2003 General Assembly
OLDER ADULTS IN NORTH CAROLINA:
A PROFILE
Prepared by the Department of Health and Human Services, Division of Aging and Adult Services
Older Population Today
North Carolina ranks tenth among states in the number of persons age 65 and older and eleventh
in the size of the entire population.i The fast pace of growth of the State’s older population is
evident in a recent US Census Bureau’s release in which North Carolina was ranked fourth
nationally in the increase of the number of older persons age 65+ (47,198 in NC) between April
2000 to July 2003. Only three other states (California, Texas, and Florida) reported a greater
increase among their older populations. Even so, when combined with the equally strong growth
in other age groups, the State continues to maintain an overall healthy demographic balance
among the generations. Currently, North Carolina ranks thirty-third nationally in the percentage
of the population that is 65 years of age and older (65+).
§ North Carolina population age 65+ in 2004: 1,016,214 (12.1% of total population)
§ North Carolina population age 85+ in 2004: 118,511 (1.4% of the total population)
North Carolina is rich in diversity, but its citizens face challenges because of the disparity that
exists among all populations, including older adults. Some important differences among the
State's older adults relate to gender, marital status, race/ethnicity, residence, rurality, disability,
health status, and veteran status.
§ Gender: Older women represent 59.8% of the 65+ age group and 74.0% of the 85+ age
group.ii The higher rate of poverty among older women remains a primary issue today. For
example, women age 75+ are twice as likely to be poor as men the same age.iii
§ Marital Status: At age 65 and older, women are more than twice as likely to be unmarried as
men in their age group.iv Data show that being unmarried (widowed, divorced, separated, or
never married) increases a woman’s vulnerability to poverty. According to the Social
Security Administration, 50% of unmarried women rely on Social Security for 80% of their
income and 25% rely on Social Security as their sole source of income.v
Age 65-74 Age 75-84 Age 85+
Unmarried Women in NC 45.4% 65.8% 76.5%
Unmarried Men in NC 18.7% 25.2% 39.4%
Source: NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007
North Carolina Aging Services Plan
§ Ethnicity/Race: Altogether 18.1% of persons age 65+ are members of ethnic minority groups
in North Carolina.vi Compared to the nation as a whole, North Carolina’s population age 65+
includes a larger proportion who are African American (15.3% in NC to 8.3% nationally) and
a smaller proportion of Latinos (0.6% in NC to 4.7% nationally). American Indians, Asian
Americans, and other ethnic groups each account for 1% or less of the age group 65+. The
statistics for African American and other older adults who are minority group members, in
North Carolina as well as nationally, show both a higher poverty rate and a lower life
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 8
expectancy when compared with the white population.
65+ White Minority
Total Male Female Male Female
Below Poverty 13.2% 6.5% 12.9% 21.7% 30.3%
“Near Poor”(101-200% Poverty) 23.2% –* –* –* –*
Life Expectancy at Birth (years) 75.6 73.8 79.6 68.0 75.8
Life Expectancy at Age 65 (years) 17.1 15.4 18.9 13.8 17.8
*Information currently not available.
Source: NC Division of Public Health (2002). Healthy Life Expectancy in North Carolina, 1996-2000.
§ Residence: In North Carolina, 23.8% of all homeowners are age 65+, yet among older
homeowners, over 61,000 reported incomes for 1999 that were below poverty.vii This figure
represented 38% of the homeowners of all ages with income below poverty and exceeded the
national average of 32.7%. Among renters age 65+ who provided information, 53%, or
almost 48,000, spent more than 30% of their household income on rent. Furthermore, 5,000
North Carolina homeowners and renters age 65+ lacked complete plumbing facilities in their
homes.viii Even more disturbing news is found in the statistics of emergency shelters—where
the largest increase among the homeless between 2001 and 2002 in North Carolina were
among those 55+.ix While the total population of homeless reported by shelters increased by
5% during this period, the elder homeless grew by 71% (totaling 3,494 persons in 2002).
§ Rurality: Although the United States Census Bureau has not yet released figures specifically
for the older population residing in rural areas, it is expected to easily exceed 39.8%, the rate
for the total population.x In 2000, North Carolina's rural population (3,199,831) was almost
as large as the one in Texas (3,647,539), the state with the largest number of rural residents in
the nation. Not only was North Carolina's rural population among the largest in terms of
numbers, but the state also reported the highest proportion (39.8%) of rural population
among the 20 most populous states in the nation. While 11 other states reported higher
proportions of rural population, ranging from 40.7% to 61.8%, all of these states are much
smaller in total population than North Carolina. Thus, North Carolina is unique among more
populous states in having so large a rural contingent. A 2002 report highlights a long list of
challenges rural residents and their communities face—isolation by distance, lagging
infrastructure, sparse resources that cannot adequately support education and other public
services, and weak economic competitiveness.xi
§ Disability: In North Carolina, 45.7% of the non-institutionalized civilian population age 65+
reported having one or more disablities•47.5% of women and 43.2% of men, according to
the 2000 Census.xii The Census defines disability as “a long-lasting physical, mental, or
emotional condition. This condition can make it difficult for a person to do activities such as
walking, climbing stairs, dressing, bathing, learning, or remembering. This condition can
also impede a person from being able to go outside the home alone or to work at a job or
business.”
§ Health Status: In a statewide survey, over one third of people age 65+ say that their general
health status is fair or poor, ranging from 34.1% for white women to 49.3% for minority
women.xiii In the same survey, 18.4% (highest) of minority women and 4.4% (lowest) of
white men age 65+ said that there was a time they could not see a doctor due to medical cost.
North Carolina Study Commission on Aging 9
Report to the Governor and the 2004 Session of the 2003 General Assembly
§ Veteran Status: Of the 779,393 veterans living in North Carolina, 263,102, or 34%, were age
65 and older in 2000. Another 34% were Vietnam-era veterans (between 43 and 57 years old
in 2000). The population of veterans of the Vietnam-era contains proportionally more
disabled members than the veterans’ populations of earlier wars.xiv The Veterans
Administration cites the aging of the veterans as a major challenge to its health care system
in coming years.xv
North Carolina’s Demographic Shift
Older adults are North Carolina’s fastest growing population. By 2030, our senior population
should exceed more than 2.2 million, comprising 17.9% of total population.xvi The median age
climbs from 35.3 years in 2000 to 38.4 years in 2030.
Projected Growth of Population Age 65+ (2000 – 2030)
969,048
1,183,243
1,652,288
2,221,470
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
2000 2010 2020 2030
Year
Population Age 65+
Why This Demographic Shift
A combination of improved life expectancy and lower birth rates contributes to a society’s
“aging”. In North Carolina, as anywhere in the nation, the aging of the “Baby Boomers” (born
between 1946 and 1964) will greatly accelerate this societal aging in coming years. Another
factor in the State’s aging is migration. North Carolina ranked sixth among the states with a net
migration rate of 22.1 per 1,000 among persons age 65+, in the five-year period between 1995
and 2000. [Note: A positive net migration indicates that more older adults moved to North
Carolina than left during that time.] Along with other Sunbelt states, North Carolina remains a
popular destination for people of all ages, including seniors. Other southern states with high
positive net migration among older adults include: Florida (56.9); South Carolina (33.6); Georgia
(18.1); and Tennessee (15.2).
There are other important factors influencing the diverse experiences in demographic shifts
among the State’s 100 counties.xvii In 83 counties, the rate of increase among citizens age 65+
(22%) is expected to exceed the growth of the total population (18%).
§ Rural-to-urban migration of young adults continues to age rural counties.
§ Large metropolitan counties attract large numbers of persons from outside the State as well as
from rural counties.
§ The large metropolitan counties are experiencing greater growth among younger adults than
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 10
they are among older adults.
§ A large number of older adults with higher incomes are retiring in some western and coastal
counties.
What Are the Implications of This Shift?
The aging of the population is a national and international trend, and North Carolina, like the rest
of the world, must be prepared to reap the benefits and face the challenges of an older
population. Government faces decisions about the allocation of public resources from a tax base
that may experience slowed growth, especially in many aging rural counties. People must
consider living and caregiving arrangements in light of smaller nuclear and extended families.
The health, human service, employment, and education systems must adapt to the changing
needs and interests of seniors of today and tomorrow. The business, faith communities, and
others must identify and respond to the challenges and opportunities of these demographic shifts.
In the 2003-2007 State Aging Plan, the North Carolina Division of Aging and Adult Services
introduced a new initiative–Senior-Friendly Communities–to raise awareness of the aging of our
population and to promote the North Carolina communities becoming senior-friendly through
collaboration among citizens, agencies, organizations, and programs, in both the public and
private arenas. A senior-friendly community in North Carolina will draw on the talents and
resources of active seniors while enhancing services for those are vulnerable because of their
health, economic hardships, social isolation, or other conditions. A senior-friendly community
will bring together a wide range of issues and concerns (e.g., air quality, housing, long-term care
services, employment, enrichment opportunities) that, as a whole, affect the quality of life of
seniors and others in the community. Also, a senior-friendly community will assure stewardship
of its resources to meet the needs of today’s seniors, while helping baby boomers and younger
generations prepare for the future.
For additional information on North Carolina aging demographics, please refer to Appendix A.
Sources of Information
1 US Census Bureau (2004). Annual Estimates of the Resident Population by Selected Age Groups for the United States and
States: July 1, 2003 and April 1, 2000.
1 NC State Data Center (2004). County/State Population Estimates.
1 Institute for Research on Women & Gender (2002). Difficult Dialogues Program Consensus Report: Aging in the Twenty-first
Century.
1 US Census Bureau (2002). PCT 7 (Summary File 3).
1 US Social Security Administration (1998). Fast Facts & Figures about Social Security.
1 US Census Bureau (2003). P12 (Summary File 1).
1 US Census Bureau (2002). HCT 8 (Summary File 2).
1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging.
1 NC Office of Economic Opportunity (2002). Comparison of Beneficiary Characteristics: Emergency Shelter Grants Program
(FY 2000 and FY 2001).
1 US Census Bureau (2003). P2 (Summary File 1).
1 MDC (2002). State of the South 2002.
1 US Census Bureau (2003). PCT 26 (Summary File 3).
1 NC Department of Health and Human Services (2003). A Health Profile of Older North Carolinians.
1 US Department of Veterans’ Affairs (2002). VA History in Brief.
1 US Department of Veterans’ Affairs (2002). Data on the Socioeconomic Status of Veterans and on VA Program Usage.
1 NC State Data Center (2004). County/State Population Projections.
1 NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina
Aging Services Plan.
North Carolina Study Commission on Aging 11
Report to the Governor and the 2004 Session of the 2003 General Assembly
COMMISSION PROCEEDINGS
February 10, 2004
The North Carolina Study Commission on Aging met on Tuesday, February 10, 2004 at 10:00
a.m. in Room 643 of the Legislative Office Building. Representative Edd Nye was the presiding
Co-Chair. Following Commission member introductions and approval of the budget, Theresa
Matula, Commission staff, provided an overview of the statutory basis for the Commission and
its charge. By law, the Commission is required to study and evaluate the existing system of
delivery of State services to older adults and to recommend an improved system of delivery to
meet the present and future needs of older adults. Mrs. Matula pointed out the specific duties of
the Commission as they appear in G.S. 120-181, and the reporting requirements contained in
G.S. 120-187.
Theresa Matula and Dianna Jessup, Commission staff, reviewed the status of the Commission's
recommendations to the 2003 Session of the 2003 General Assembly and presented an overview
of other legislation of interest to older adults Appendix B.
Karen Gottovi, Director, Division of Aging and Adult Services, Department of Health and
Human Services (DHHS), presented an overview of the services available for older adults in
North Carolina Appendix C. Mrs. Gottovi also presented The Aging of North Carolina, the
2003-2007 North Carolina Aging Services Plan. The Plan was submitted to the North Carolina
General Assembly on March 1, 2003. Mrs. Gottovi pointed out that the 2003-2007 Plan builds
upon the achievements of the 1999-2003 Plan as well as three other earlier plans developed in
the 1990s (1991, 1993, and 1995) and provides a foundation for new developments. The Aging
Services Plan is required by G.S. 143B-181.1A and the federal Older American Act.
John Saxon, Professor of Public Law and Government, University of North Carolina at Chapel
Hill gave a presentation on guardianship laws. Appendix D. The presentation outlined the legal
history of guardianship reform, the current law and issues that may need to be addressed, as well
as and overview of the Uniform Guardianship and Protective Proceedings Act (UGPPA).
The North Carolina tax credit for long term care insurance expired for taxable years beginning
on or after January 1, 2004. As a result, the Commission heard from Carla Obiol with the
Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), who gave an
overview of long term care insurance. Her handouts included: A Shopper's Guide to Long-Term
Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Additionally,
Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes
Division, of the North Carolina Department of Revenue, made presentations on the tax treatment
of long-term care insurance in selected states, and on the number of long-term care tax credits
claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on
the long-term care tax credit and the Department's efforts to reduce that error rate. Some of the
Department's efforts include informing taxpayers who made errors, and working with software
vendors to improve the long-term care tax credit information in their programs.
The final item on the agenda concerned adult care home rules and caring for the mentally ill.
The Commission heard presentations from Jim Upchurch, Division of Facility Services,
Department of Health and Human Services Appendix F; Dottie Harrison, Board Member, NC
National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association of Long Term
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 12
Care Facilities. Ms. Harrison addressed the consequences of the lack of appropriate housing for
mentally ill individuals and her concerns for adequate staffing and training to care for mentally
ill individuals in long-term care facilities. Ms. Wilson mentioned the use of the Geriatric Mental
Health Specialty Teams and provided recommendations for improvement.
March 9, 2004
The North Carolina Study Commission on Aging met on Tuesday, March 9, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co-
Chair. Topics of this meeting included brief remarks by organizations advocating on behalf of
older adults in North Carolina; disease management; NC Senior Care; the new Medicare
prescription drug program; and geriatric mental health specialty teams.
The Commission heard from fifteen (15) individuals that represent, or advocate on behalf of,
older adults in North Carolina. Each representative was allowed approximately three minutes to
make a brief presentation on the issues affecting older adults in North Carolina. Staff presented
the Commission members with a Summary of Presentations by Organizations Representing
Older Adults Appendix G during the March 23, 2004 meeting. The legislative priorities/issues of
concern that were mentioned with the greatest frequency were: Access to National Criminal
Record Checks (6 responses); Restoration of the LTC Insurance Tax Credit (4 responses);
Support for and/or Restoration of Funding for the home and Community Care Block Grant
(HCCBG) (3 responses); Support for/and or Restoration of Funding for Senior Centers (3
responses); and Maintaining the Viability of the Community Alternatives Program for Disabled
Adults (CAP/DA) (3 responses) Appendix G.
Alan Dobson, Chairman of Cabarrus Community Care; Chairman of Physician Advisory Group;
and President/CEO of Cabarrus Family Medicine delivered a presentation on disease
management. Community Care of North Carolina focuses on improved quality, utilization and
cost effectiveness with thirteen (13) networks with more than 2,000 physicians and 417,000
enrollees. Dr. Dobson indicated that the primary goals of Community Care of North Carolina
are to: Improve the care of the Medicaid population while controlling costs; and to Develop
community based networks capable of managing populations. He pointed out that these goals
are achieved by making sure people get the care when they need it; increasing local provider
collaboration; obtaining quality care; implementing best practice guidelines; and managing
Medicaid costs. Key program efforts for the aged and disabled include: diabetes, poly-pharmacy
in skilled nursing facilities, poly-pharmacy for the disabled, and therapy services.
Michael Keough, from the Department of Health and Human Services, gave a presentation on
the North Carolina Senior Care program. He first gave an overview of the program, which is
designed specifically to provide assistance to North Carolina seniors (age 65 or older), diagnosed
with one of three diseases (diabetes mellitus, cardiovascular disease, and chronic obstructive
pulmonary disease); have an annual household income at or below 200% of the federal poverty
level and no other prescription drug coverage. As of March 2004, there were 32,600 enrollees,
representing all 100 counties. Outreach efforts include the distribution of 400,000 enrollment
applications and an outreach grant with the General Baptist State Convention. Mr. Keough also
presented information on the Medication Assistance Program in which 23 grantees cover 60 sites
in 60 counties. The key components of the Medication Assistance Program include: Prescription
Assistance (facilitating use of pharmaceutical manufacturers' free and low cost drug programs),
and Medication Management including pharmacist evaluation of individual senior's drug
North Carolina Study Commission on Aging 13
Report to the Governor and the 2004 Session of the 2003 General Assembly
regimens. NC Senior Care is reviewing options to coordinate coverage with the recently
enacted changes to the Medicare program.
Carla Obiol, Deputy Commissioner, Seniors' Health Insurance Information Program (SHIIP)
made a presentation to the Commission on the Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Act). Ms. Obiol gave an overview of the timetable of benefits,
information on the Medicare Prescription Drug Discount Card and the Transitional Assistance
Program, the discount card sponsor qualifications, Medicare Part D: Prescription Drug Plan
(PDP), and outreach efforts by SHIIP and the Centers for Medicare & Medicaid Services (CMS).
Provisions of the Act include a Medicare-approved Prescription Drug Discount Card, a
Transitional Assistance Program, and Medicare Advantage from 2004-2005. It is anticipated
that Medicare Part D: Prescription Drug Plan will be in place by 2006. Details are continuing to
evolve and Ms. Obiol recommended the following resources: the Medicare Program:
http://www.medicare.gov/ or http://www.cms.gov/ or 1-800-MEDICARE; and SHIIP
http://www.ncshiip.com./ (see Senior Citizens heading).
This meeting concluded with a presentation on Geriatric Mental Health Specialty Teams from
Dr. Bonnie Morell, Division of Mental Health, Developmental Disabilities and Substance Abuse
Services, Department of Health and Human Services. According to Dr. Morell, the Geriatric
Mental Health Specialty Teams were developed to provide expertise and services throughout the
State in recognition of the need for greater local capacity to address and serve the needs of older
adults with mental illness. According to information presented, "The purpose of these teams is to
increase the ability of older adults with mental illness to live successfully in their communities
by: 1) assisting with the successful reintegration of older adults into the community when they
are discharged from State psychiatric hospitals, and 2) providing holistic support services and
technical assistance to nursing homes, adult care homes, and other agencies and caregivers that
serve older adults who have mental health treatment needs and who may be at risk of psychiatric
hospitalization." Appendix F
March 23, 2004
The North Carolina Study Commission on Aging met on Tuesday, March 23, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Representative Debbie Clary was the presiding
Co-Chair. Presentation topics for this meeting were elder housing, the long-term care workforce,
adult day services, the Home and Community Care Block Grant (HCCBG), a report on CAP/DA,
and criminal history record checks.
Bob Kucab, Executive Director of the North Carolina Housing Finance Agency, spoke to the
Commission about the work of the agency. The purpose of the agency is to finance housing for
persons who are not served by the private market. The agency helps seniors by improving their
existing housing and by working to develop new apartments where seniors can have affordable
rents, good living environments, and connections to community services. While the agency is
involved in a number of projects, applications for funding exceed available capital by 3 to 1. Mr.
Kucab requested an increase in the $3 million State appropriation for the Housing Trust Fund to
aid the agency in its efforts.
Susan Harmuth from the Office of Long Term Care and Family Services, Department of Health
and Human Services (DHHS), updated the Commission on the Department's long-term care
workforce initiatives. She reported that employee turnover has been decreasing since 2000, but
it is still high. The Department is working on a variety of projects to combat this turnover. One
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 14
of these projects is The Better Jobs/Better Care Demonstration. Under this demonstration, the
State's Better Jobs/Better Care Partner Team is working to develop a uniform (and voluntary) set
of expectations and criteria for use across home care, adult care homes and nursing facilities that
relate to issues impacting the recruitment and retention of direct care workers. Major domain
areas include safe and balanced workloads, training and career advancement opportunities,
supportive workplaces, worker empowerment, peer mentoring, orientation, management support,
coaching supervision, and reward and recognition.
Following Ms. Harmuth's presentation, the Commission heard several presentations concerning
adult day and adult day health services. Nancy J. Cox, Director of Partners in Caregiving, Wake
Forest University School of Medicine, presented information concerning the predictors of
success for adult day programs from a marketing, financing, and programming perspective.
Created in 1987 by The Robert Wood Johnson Foundation, Partners in Caregiving is a national
adult day services program. The focus of Partners in Caregiving is to teach non-profit adult day
centers the principles of business and marketing to be financially self-sufficient and not rely on
grants. She presented the results of a recent national study of adult day services that showed the
need for adult day service capacity building at the State level in three areas: increased public
awareness in underutilized areas, increased availability in areas where the service is not currently
an option for caregivers, and increased knowledge at the provider level regarding predictors of
success.
Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the
challenges of operating a successful adult day program. Ms. Kennedy showed pictures of the
facilities in her area and presented the "Menu for Financial Success for the Life Enrichment
Center." This Menu included: 1) a strong Board with effective committees; 2) diversified
revenue streams (operating and non-operating); 3) a diversified population; 4) unbundling the
services (i.e. transportation, personal care services, hair care); and 5) pre-billing for enrollment
rather than attendance, for the levels of care, and for ancillary services. Ms. Kennedy stated that,
"Without financial stability there can be no social good," and she pointed out that public
reimbursement rates are often insufficient to cover the costs of running a program.
Steve Freedman from the Division of Aging and Adult Services, DHHS, was the final speaker on
the subject of adult day services Appendix I. Mr. Freedman stated that there are currently 113
certified adult day and adult day health programs in the State, a decrease from the peak of 125
programs in 2000. The programs are currently located in 60 counties. The Division of Aging
and Adult Services has been working with the North Carolina Adult Day Services Association to
develop fiscal training for adult day programs. According to the Division, the aim of this project
is to assist adult day programs with budgeting and help increase their understanding of service
costs. Mr. Freedman also addressed reimbursement rates. Currently, the maximum
reimbursement rate for adult day services is $26.07 per day, and $33.00 per day for adult day
health services. According to the North Carolina Adult Day Services Association, the average
cost to operate an adult day program is $31.00 per day, and for adult day health programs it is
$44.00 per day. In the 2003 budget bill, the General Assembly directed the Social Services
Commission to consider adopting rules to increase these rates within existing funds. A rate
increase has not occurred.
Next, Dennis Streets from the Division of Aging and Adult Services, DHHS presented
information concerning the Home and Community Care Block Grant Appendix H. The Home
and Community Care Block Grant (HCCBG) was established by the General Assembly in 1992.
North Carolina Study Commission on Aging 15
Report to the Governor and the 2004 Session of the 2003 General Assembly
By consolidating several funding sources (i.e. the Older Americans Act, the Social Services
Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds,
and other relevant State appropriations), the HCCBG helps to coordinate the service delivery
system to meet the needs of seniors. The focus of the HCCBG is to support the frail elderly at
home, assist with access to services and information, provide family caregiver relief and help
seniors remain active. While there have been some increases in federal funds, State support has
decreased. According to Mr. Streets, there are more than 6,500 unmet service needs, especially
for home-delivered meals and in-home aide services.
Gary Fuquay, Division of Medical Assistance, DHHS, presented a report on the Community
Alternatives Program for Disabled Adults (CAP/DA), required by S.L. 2003-284, Sec. 10.29B(b)
and (c). The section basically required the Department to conduct a cost analysis of CAP/DA
and the State/County Special Assistance In-Home program in relation to the per client cost of
nursing homes and adult care homes. While the report attempted to provide cost comparisons,
Mr. Fuquay warned that it is difficult to draw conclusions from the data because one cannot
compare level of care indicators.
The Commission next heard from various speakers concerning national criminal history records
checks of long-term care workers. John Aldridge from the North Carolina Attorney General's
Office gave an overview of current law regarding who can receive the results of national
criminal history records checks and for what purposes. Jackie Sheppard from the Office of
Long-Term Care and Family Services, DHHS, gave an overview of what the state of Mississippi
is doing to address this issue. Roger Manus, representing Friends of Residents in Long-Term
Care, urged the Commission to look at Florida's system for conducting background checks.
Stacy Flannery, representing the NC Health Care Facilities Association, presented the providers'
concerns about this issue.
Finally, the meeting concluded with a brief presentation summarizing Appendix G the
association presentations from the March 9 meeting. Chief among the issues raised by the
associations was the current moratorium on national criminal history records checks of long-term
care workers.
April 13, 2004
The North Carolina Study Commission on Aging met on Tuesday, April 13, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co-
Chair. During this meeting, the Commission heard a presentation from Jackie Franklin with the
Division of Aging and Adult Services, Department of Health and Human Services, on the
State/County Special Assistance In-Home program. The Commission discussed and initially
approved recommendations to the Governor and the General Assembly. The Commission also
directed the staff to prepare a draft report for review at the final meeting.
April 27, 2004
The North Carolina Study Commission on Aging met on Tuesday, April 27, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Members discussed and approved the
Commission’s Report to the Governor and to the 2004 Session of the 2003 General Assembly.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 16
COMMISSION RECOMMENDATIONS
The North Carolina Study Commission on Aging makes the recommendations presented in this
section to the Governor and the 2004 Session of the 2003 General Assembly. Each
recommendation is followed by background information, and corresponding legislative proposals
appear in Appendix J of this report.
Recommendation 1
The North Carolina Study Commission on Aging recommends that the General Assembly
repeal the sunset on the Long-Term Care Insurance Tax Credit.
Background
In 1997, the North Carolina Study Commission on Aging recommended that the 1997 General
Assembly enact a 15% tax credit, up to a maximum of $350, on the premiums paid by the
purchaser of long-term care insurance policies. According to the 1997 Commission report, the
Office of State Budget and Management estimated that a 15% tax credit up to a maximum of
$350 may result in a revenue loss of $17 million. The report further stated that, the average
premium was $1,600, thus a 15% credit would be equal to $240. The report acknowledged that
it was difficult to estimate the offsetting benefits of the tax credit in terms of reduced Medicaid
payments, but that the cost of a year's stay in a North Carolina nursing home was $40,000. The
Commission recommended this tax credit again in 1998, and the credit became Section 29A.6 of
Session Law 1998-212. The tax credit was effective for taxable years beginning on or after
January 1, 1999, and expired for taxable years beginning on or after January 1, 2004.
On January 16, 2003, the Department of Revenue prepared a memorandum for the Revenue
Laws Study Committee on the status of the tax credit for premiums paid on long-term care
insurance. The memorandum outlined the Department's review of some of the returns on which
the credit was claimed. During this review, auditors found that some taxpayers, who were not
eligible for the tax credits, claimed the tax credits; and that some taxpayers claimed long-term
care credits greater than the cap of $350. The Department found that, "Of the 2,155 returns
reviewed, only 192 contained allowable long-term care credits. Taxpayers were not eligible for
the credits claimed on the remaining 1,963 returns in this group. As a group, therefore, over
90% of the returns incorrectly claimed the credit." Because this represented a sample, the
Department indicated that they did not know the error rate for all returns claiming the credit.
They attributed the high error rate to two possible factors: "One factor is the complicated nature
of the credit and the other is confusion of this credit with the repealed child health insurance
credit." Additionally, the memorandum indicated that, for tax year 2001, the credit reduced tax
revenue by $10,367,883.
The 2003 North Carolina Study Commission on Aging recommended repealing the sunset on the
long-term care insurance tax credit. In its 2003 report, the Commission expressed agreement
with a statement from a Division of Aging's report, Increasing Personal Responsibility for Long
Term Care through Private Long Term Care Insurance. The Division's report stated that, "In
addition to the public benefit of having a much larger segment of the adult population positioned
to pay privately for long-term care in terms of the state's economic health, consumers and
families benefit from the ability to pay privately through increased choice and flexibility in terms
of the range of services and settings of care available." S.L. 1998-212, Section 29A.6(d) made
North Carolina Study Commission on Aging 17
Report to the Governor and the 2004 Session of the 2003 General Assembly
the credit for premiums paid on long-term care insurance effective for taxable years beginning on
or after January 1, 1999, and sunset the credit effective January 1, 2004. The Commission's bills
repealing the sunset were introduced during the 2003 Session, but were not successful and the
tax credit was allowed to sunset. As a result, the tax credit is not currently in place for the 2004
tax year.
During the February 10, 2004 meeting, the Commission heard a presentation on long-term care
insurance from Carla Obiol with the Seniors' Health Insurance Information Program (SHIIP),
and presentations on issues related to the tax credit from Department of Revenue employees Karl
Knapp, Tax Research Division, and Nancy Pomeranz, Personal Taxes Division Appendix E.
Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program
(SHIIP), gave an overview of long-term care insurance. Her handouts included: A Shopper's
Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North
Carolina . Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal
Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax
treatment of long-term care insurance in selected states, and on the number of long-term care tax
credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate
experienced on the long-term care tax credit and the Department's efforts to reduce that error
rate. The Department indicated that they had made progress in reducing the error rate on the
long-term care insurance tax credit. Commission staff also obtained a chart Appendix E from the
American Association of Health Plans-Health Insurance Association of America (AAHP-HIAA)
depicting those states in the United States that offer tax incentives for the purchase of long-term
care insurance. AAHP-HIAA is a national trade association representing the private sector in
health care. The chart from AAHP-HIAA shows that 6 states offer tax credits and 16 states offer
tax deductions. (Note: The information in the AAHP-HIAA chart does vary from the Department
of Revenue's information, which could be the result of different compilation dates.)
According to information received by the Commission staff, on June 5, 2003, the Department of
Revenue reported that they had audited 2,372 returns for the tax year 2002, and adjusted 650 to
disallow the credit, representing a 27% error rate. This error rate was down considerably from
the 90% error rate on the 2001 returns reported earlier by the Department. The Department
attributed the decrease to: 1) informing tax preparers of the appropriate use of the credit; 2)
clarifying instructions about eligibility for the credit; 3) improving the verbiage in software
developers' tax packages; and 4) communicating with taxpayers whose credit was disallowed in
2001, to inform them of the eligibility criteria for the tax credit. An additional $279,628 was
assessed on the 650 returns adjusted, and returns continue to be audited as resources permit. On
November 3, 2003, the Department reported that they had processed 3,574,530 returns:
2,158,850 paper and 1,415,680 efiled. Of the total, there were 35,936 on which a credit for long-term
care insurance was claimed for a total of $19,110,623.
The North Carolina Study Commission on Aging has supported the long-term care insurance tax
credit since its inception and the current Commission continues to support it. The Commission
scheduled presentations on this issue at the first meeting this interim, and restoration of the long-term
care insurance tax credit was an item mentioned frequently during presentations on March
9, 2004, by organizations representing older adults in North Carolina. The Commission
recommends that the General Assembly repeal the sunset on the long-term care insurance tax
credit.
Recommendation 2
The North Carolina Study Commission on Aging recommends that the General Assembly
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 18
require the Department of Health and Human Services to continue to provide support and
training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams;
and by standardizing criteria across the Teams and tracking utilization and expenditure
data.
Background
On February 10, 2004, the Commission heard presentations on adult care home rules and caring
for the mentally ill from Jim Upchurch, Division of Facility Services, Department of Health and
Human Services (DHHS); Dottie Harrison, Board Member, NC National Alliance for the
Mentally Ill (NAMI); and Lou Wilson, NC Association Long Term Care Facilities. On March 9,
2004, the Commission heard a presentation on Geriatric Mental Health Specialty Teams from
Bonnie Morell, Community Policy Section, Division of Mental Health, Developmental
Disabilities and Substance Abuse Services, Department of Health and Human Services (DHHS).
Appendix F
During her presentation, Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty
Teams. She indicated that while the intent of the program was positive, she believed, "The State
has provided very little guidance for area mental health programs as to how the teams should be
operated, thus the program has floundered in many areas of the state." She also stated that,
"Area programs all over the State have developed criteria, protocol, policies and procedures that
are unique to their area program. As a result, consumers and providers of services are expected
to muddle through a system of inconsistency."
According to information provided by DHHS, Geriatric Mental Health Specialty Teams were
developed to increase the ability of older adults with mental illness to live successfully in their
communities by: 1) assisting with the successful reintegration of older adults into the community
when they are discharged from State psychiatric hospitals; and 2) providing holistic support
services and technical assistance to nursing homes, adult care homes, and other agencies and
caregivers that serve older adults who have mental health treatment needs and who may be at
risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who
are preparing to enter a nursing home or an adult care home, who currently reside in a nursing
home or adult care home, and who are living in their own home or with family members.
Individuals with geriatric-like needs are also served. Dr. Morell noted that, "This is a fairly new
program that is being implemented during a time of change in the public mental health system.
Focus will be on identifying ways in which to support the work that is being done by the teams
that have been put in place."
During her presentation on February 10, 2004, Ms. Wilson shared a recommendation for
legislation. Ms. Wilson's recommendations include: 1) renaming the Teams to Long Term Care
Facility Specialty Teams; 2) requiring all licensed adult care homes and nursing homes that serve
individuals with a mental illness to participate in the program; 3) deleting the age requirement
and the restrictions for residents to be at risk of psychiatric hospitalization and making services
available for all persons with a mental illness who reside in adult care homes and nursing homes;
4) increasing the number of professionals on each team and/or decreasing the geographic areas
that each team covers; 5) developing standardized criteria; 6) fully funding the program to
support the individuals and facilities eligible for services; and 7) repealing the current adult care
home special unit rule for persons with mental illnesses and create a new licensure law and rules
that are more realistic.
North Carolina Study Commission on Aging 19
Report to the Governor and the 2004 Session of the 2003 General Assembly
According to information provided by staff in the General Assembly's Fiscal Research Division,
the Geriatric Mental Health Specialty Teams are a contracted service through the Local
Management Entities (LME). There are 20 Teams across North Carolina and each one contracts
with one or more LME's. These are funded with Mental Health Trust Fund dollars, and these
non-recurring funds are being replaced by recurring funds made available through mental
hospital downsizing. As a Team delivers services to a facility, they file for reimbursement with
the LME, which in turn seeks reimbursement from DHHS. Currently, DHHS cannot report
specific cost data on the Geriatric Mental Health Specialty Teams.
Based on the information presented to the Commission, the Commission recommends that the
General Assembly require the Department of Health and Human Services to continue to provide
support and training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and
by standardizing criteria across the Teams and tracking utilization and expenditure data.
Recommendation 3
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to work with long-term care
providers and advocates for the elderly and the mentally ill to study issues related to
mentally ill individuals residing in long-term care facilities.
Background
On February 10, 2004, the Commission heard presentations concerning caring for mentally ill
individuals in long-term care facilities. One of the presenters was Dottie Harrison, Board
Member, NC National Alliance for the Mentally Ill (NAMI). Ms. Harrison questioned whether
adult care homes were appropriate housing options for mentally ill individuals, and she
questioned the appropriateness of staffing and training at these facilities. Specifically, Ms.
Harrison supported training on the appropriate administration of psychiatric medications, and
training on appropriate interaction with residents based on their particular mental illness.
Another presenter at the February meeting, Lou Wilson, Executive Director of the North
Carolina Association of Long Term Care Facilities, stated that adult care home providers,
"simply do not know how to muddle through the complex mental health systems, develop good
rapports with mental health providers, provide mental health training for staff and recognize
issues when specific residents are having difficulty." Ms. Wilson requested training for adult care
home staff that will enable them to recognize symptoms of mental illness and urged the State,
advocates, and the industry, to work together to ensure that individuals with mental illnesses
receive the services they are entitled to receive.
During the March 9, 2004 meeting, Dr. Bonnie Morell shared information with the Commission
on the Geriatric Mental Health Specialty Teams Appendix F. One of the purposes of these
Teams is to provide support services and technical assistance to nursing homes, adult care
homes, and other agencies and caregivers that serve older adults who have mental health
treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams
serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care
home, who currently reside in a nursing home or adult care home, and who are living in their
own home or with family members. Individuals with geriatric-like needs are also served.
In addition to other recommendations, Lou Wilson also requested the creation of a new licensure
law and rules that are more realistic. During discussions at the April 13, 2004 meeting,
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 20
Commission members voiced support for examining whether current State statutes and
Departmental rules adequately address the populations served by long-term care facilities. They
also supported examining adult care home rules to determine whether they are easy to
understand, attainable under current staffing patterns, give appropriate guidance to facility
operators according to the needs and characteristics of residents served, support resident's
freedom of choice, and whether they support the autonomy, dignity and independence
philosophy of assisted living.
The Commission supports quality care for mentally ill individuals and elderly individuals and
recommends that the General Assembly require the Department of Health and Human Services
to work with long-term care providers and advocates for the elderly and the mentally ill to study
issues related to mentally ill individuals residing in long-term care facilities.
Recommendation 4
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a pilot program to conduct national criminal history record checks of persons
seeking employment to provide direct care in adult care homes or contract agencies of
adult care homes.
Background
State law currently requires criminal history record checks of all applicants for employment with
nursing homes, home health care agencies, and adult care homes. If the applicant has been a
resident of North Carolina for less than five years, the criminal history record check must include
both a national and a State criminal history record check. If the applicant has been a resident of
North Carolina for five years or more, only a State criminal history record check is required.
However, under federal law, the FBI may release results of national criminal history checks
directly to nursing homes and home health care agencies on applicants for positions that involve
direct patient care. Otherwise, results of criminal history checks performed by the FBI can only
be released to a state agency and cannot be released directly to a provider. This has made it
difficult for providers to comply with State law. As a result, a moratorium on national criminal
history record checks was instituted in S.L. 2002-126, Sec. 10.10C for applicants for positions in
nursing homes and home care agencies other than those involving direct patient care and for
applicants for all staff positions in adult care homes, until January 1, 2004. Session Law 2003-
284, Sec. 10.8E extended the moratorium to January 1, 2005.
Access to national criminal history record checks was an item mentioned frequently during
presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older
adults in North Carolina. On March 23, 2004, the Commission heard a presentation from John
Aldridge of the North Carolina Attorney General's office on this issue. He reiterated that unless
federal law provides otherwise, the results of a national criminal history record check can only be
released to a governmental agency. Currently, federal law only permits these results to be
released to nursing homes and home care agencies on applicants for positions that involve direct
patient care. Therefore, in order to be able to conduct national criminal history record checks on
applicants for positions in nursing homes and home care agencies that do not involve patient care
and on applicants for positions in adult care homes, current State law would have to be changed
to direct that the results be sent to a governmental agency.
The Commission recognizes that long-term care advocates and providers have legitimate
concerns about the current status of national criminal history record checks. Roger Manus,
North Carolina Study Commission on Aging 21
Report to the Governor and the 2004 Session of the 2003 General Assembly
President of Friends of Residents in Long Term Care, pointed out during the Commission's
meeting on March 23, that people living in long-term care facilities are the vulnerable frail
elderly and disabled that cannot defend themselves, and many cannot communicate when they
perceive a threat. Worst of all, they spend the night in these facilities when staffing levels
decrease even further with greater potential and opportunity for abuse. It is important to ensure
the safety of this vulnerable population. On the other hand, the Commission recognizes that
employee turnover is high in long-term care facilities. It is important that providers be able to
fill positions quickly and not have to wait an inordinate amount of time for a determination to be
made by an agency about whether an applicant is disqualified because of the applicant's criminal
background. Questions arose during the Commission's deliberations about the State's
technological and staffing capacity to be able to turn around a determination of disqualification
quickly.
The Commission recommends moving this issue forward by establishing a pilot program to
conduct national criminal history record checks of workers in adult care homes and contract
agencies of adult care homes who provide direct resident care and requiring the Department of
Health and Human Services to collect information and meet regularly with providers and others
to monitor the progress of the pilot to determine what is needed in order to fully implement the
national criminal history record checks as the General Assembly intended.
Recommendation 5
The North Carolina Study Commission on Aging recommends that the General Assembly
support Senior Center development and outreach, and restore funding to the 2002 level, by
appropriating $281,000 for the 2004-2005 fiscal year.
Background
Senior Centers are resources within communities that typically provide nutrition, recreation,
social and educational services, and comprehensive information and referral. The National
Institute of Senior Centers defines a senior center as a place where “older adults come together
for services and activities that reflect their experience and skills, respond to their diverse needs
and interests, enhance their dignity, support their independence, and encourage their involvement
in and with the center and the community.” Prior to the 2002 Session, State funds for Senior
Centers were $1,365,316. During the 2002 Session, funds were reduced by $381,000. During the
2003 Session, $100,000 was restored, and the local match requirement was increased.
Support for and/or restoration of funding for Senior Centers was an item mentioned frequently
during presentations on March 9, 2004, by organizations representing, or advocating on behalf
of, older adults in North Carolina Appendix G. To fully restore State funding to the prior level,
an additional $281,000 would be needed. Therefore, the Commission recommends that the
General Assembly support Senior Center development and outreach, and restore funding to the
2002 level, by appropriating $281,000 for the 2004-2005 fiscal year.
Recommendation 6
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used
for independent housing with services.
Background
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 22
The Housing Finance Agency mission is to create affordable housing opportunities for North
Carolinians whose needs are not met by the market. This mission is accomplished through
helping older individuals age in place by improving existing housing, and by working to develop
new apartments for older adults. In the March 23, 2004 presentation, Bob Kucab, Executive
Director, stated that applications for funding requests currently exceed available capital by 3:1.
State funds help bring in outside funding because the Housing Finance Agency is able to
leverage $5 in development from every $1 the State invests. According to Mr. Kucab, all State
funds that they administer are invested in bricks and mortar; staff costs are paid from their
revenue. Mr. Kucab reported that, State appropriations are currently down to $3 million from a
high of $9 million.
The Commission recognizes the need for new apartments with affordable rent, where older
adults can enjoy safe and comfortable living environments, and connections to community
services. Therefore, the Commission recommends that the General Assembly appropriate
$1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent
housing with services.
Recommendation 7
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005
fiscal year.
Background
On March 23, 2004, Dennis Streets, Division of Aging and Adult Services, DHHS, made a
presentation to the Commission on the Home and Community Care Block Grant (HCCBG)
Appendix H. His presentation gave an overview of the program; eligibility criteria; and
information on program utilization, availability, and needs. The HCCBG is established by G.S.
143B-181.1(a)(11). Mr. Streets pointed out that by "consolidating several funding sources (i.e.,
the Older Americans Act, the Social Services Block Grant in support of respite care, portions of
the State In-Home and Adult Day Care funds, and other relevant State appropriations)—some of
which traditionally went to separate organizations—the HCCBG represented an important step
toward establishing a well coordinated service delivery system to meet the needs of a rapidly
growing older population." The HCCBG includes federal funds, State funds, local funds, and a
client cost sharing component. The two principal purposes of the HCCBG are to give counties
greater discretion, flexibility and authority in determining services, service levels and service
providers; and to streamline and simplify the administration of services. The HCCBG focuses
on: supporting frail elderly in their preference to be cared for at home; improving and
maintaining the physical and mental health of older adults; assisting older adults and their
caregivers with accessing services and information; providing relief to family caregivers so that
they can continue their caregiving; and allowing older adults to remain actively engaged with
their communities.
Any person age 60 and older is eligible for services under the HCCBG. The HCCBG program
places an emphasis on reaching those most in need of services (the Older Americans Act (OAA)
gives priority to serving the "socially and economically needy" -with particular attention to low-income
minority elderly and older individuals residing in rural areas). Additionally, the OAA
calls for reaching out to older individuals with severe disabilities, limited English-speaking
ability, and Alzheimer's disease or related disorders (and caregivers of these individuals).
North Carolina Study Commission on Aging 23
Report to the Governor and the 2004 Session of the 2003 General Assembly
State appropriations for the HCCBG were $25,128,469 for the 2002-2003 fiscal year. State
appropriations were cut by $1,055,690 to $24,072,799 for the 2003-2004 fiscal year. State
appropriations are currently slated to be reduced to $24,026,079 for the 2004-2005 fiscal year.
An increase in federal Older Americans Act funds has helped to offset the decrease in State
funding and overall funding of the program was down from the previous year only $341,603 for
2003-2004. However, the Division anticipates a decrease in federal funding for 2004-2005,
which would leave the overall total down another $389,974. Unless the General Assembly
increases State appropriations, the total net funding for HCCBG would be down $731,577 for the
period from 2002-2003 to 2004-2005.
Support for and/or restoration of funding for the HCCBG was an item mentioned frequently
during presentations on March 9, 2004, by organizations representing, or advocating on behalf
of, older adults in North Carolina Appendix G. The Commission recognizes the vital services
that are provided under the HCCBG and recommends that the General Assembly appropriate
$1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year.
Recommendation 8
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to study whether the State's
Medicaid Program has a bias that favors support for individuals in institutional settings
over support for individuals living at home; and to recommend ways to alleviate this bias,
if such a bias exists.
Background
The Final Report by The North Carolina Institute of Medicine Task Force on Long-Term Care
reported an institutional bias in Medicaid eligibility rules. The report states that a reason public
funding is weighted toward institutional care is that Medicaid and other public program rules
make it easier for people to qualify for financial assistance with institutional or residential care
than for services provided at home or in the community. Under existing laws, individuals can
qualify for either nursing home care or State-County Special Assistance for adult care homes
with higher monthly incomes than they can if they want to obtain Medicaid coverage for health
services provided in their own home. With these different income eligibility limits, individuals
living at home who may have too much income to qualify for Medicaid coverage as long as they
remain in their home, may qualify if they move into a more costly institutional or residential
setting.
In Olmstead v. L.C., the United States Supreme Court concluded that inappropriate
institutionalization of a person with a mental disability may be discrimination under ADA. The
Commission recognizes that the law favors caring for an individual in the community rather than
in an institution, and institutional care may be more costly than residential care. Therefore, the
Commission recommends that the General Assembly direct the Department of Health and
Human Services to study whether an institutional bias in Medicaid eligibility rules do in fact
exist and if they do exist, to determine how to alleviate the bias.
Recommendation 9
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a Legislative Study Commission to study State guardianship laws.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 24
Background
Guardianship is a legal relationship in which a person or agency (the guardian) is appointed by a
court to make decisions and act on behalf of another person (the ward) with respect to the ward’s
personal or financial affairs because the ward, due to a specific mental or physical impairment,
lacks sufficient capacity to make or communicate important decisions concerning his or her
person, family, or property or lacks sufficient capacity to manage his or her personal or financial
affairs. Laws regarding guardianship for incapacitated adults attempt to strike a balance between
preserving the legal rights, freedom, and autonomy of individuals vs. society’s duty (parens
patriae) to protect individuals who are unable to protect or care for themselves.
On February 10, 2004, the Commission heard a presentation on "Guardianship Reform in the
Twenty-First Century" Appendix D by John Saxon, Professor of Public Law and Government,
UNC Chapel Hill. According to his presentation, the last substantive revision to the guardianship
law was in 1977, and the last consolidation and clarification was enacted in 1987. Since 1987,
there have been efforts to review and revise the statutes, but none resulted in change. Current
law consists of an assortment of statutes, some of which date back to the 1800s. As a result,
there are a number of issues in the guardianship statutes that need review and updating, including
interstate jurisdiction, the definition and standard of incapacity, due process, guardianship
alternatives, limited guardianship, the guardian's powers, and the role of human service agencies.
Professor Saxon suggested that as an alternative to rewriting current law, North Carolina could
adopt the Uniform Guardianship and Protective Proceedings Act (UGPPA). The UGPPA has
been enacted in four states. The UGPPA authorizes two types of legal proceedings: guardianship
proceedings to appoint guardian (guardian of the person) for a minor or incapacitated person; and
protective proceedings regarding the property of a minor or a missing, absent, detained, or
incapacitated person, including proceedings seeking the appointment of a conservator (i.e.
guardian of the estate). Under the UGPPA, guardianship and conservatorship is viewed as last
resort. A guardian or conservator may be appointed only if there are no other lesser restrictive
alternatives that will meet the respondent’s needs, and limited guardianship or conservatorship
should be used whenever possible. According to Professor Saxon, the UGPPA is advantageous
because it is modern, comprehensive, legally adequate, balanced, proven, and could be
customized to address any issues that are unique to North Carolina.
The North Carolina Study Commission on Aging recognizes that the laws pertaining to
guardianship are important for the protection of citizens who are unable to make personal
decisions due to impairment or incapacity, and that these laws have not been thoroughly
reviewed in 17 years. Therefore, the Commission recommends the General Assembly establish a
Legislative Study Commission on State Guardianship Laws.
Recommendation 10
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate funds and require the Social Services Commission to adopt a rate increase of
no less than five dollars ($5.00) per day for adult day and adult day health services.
Background
North Carolina General Statute 131D-6 provides that adult day care enables people who would
otherwise need full-time care away from their own residences to remain in their residences as
long as possible. An adult day care program provides group care and supervision for physically
or mentally disabled adults in a place other than their usual place of abode on a less than 24-hour
North Carolina Study Commission on Aging 25
Report to the Governor and the 2004 Session of the 2003 General Assembly
basis. Adult day services include a social model and a health model. Both models provide a
community setting that promotes social interaction, and physical and emotional well-being.
Adult day health programs also offer health care services to meet the needs of individual
participants. Nutritional meals and snacks are provided and transportation to and from the
program may be provided or arranged when needed. Often these programs provide a safe
stimulating environment while a primary caregiver is at work. Providers of adult day care must
meet North Carolina State Standards for Certification. The Social Services Commission sets
these standards and the reimbursement rates paid for adult day and adult day health services.
During the March 23, 2004 meeting, the Commission heard from Nancy J. Cox, Director of
Partners in Caregiving, Wake Forest University School of Medicine; Suzi Kennedy from the Life
Enrichment Center of Cleveland County, Inc.; and Steve Freedman from the Division of Aging
and Adult Services, DHHS Appendix I. The Commission received information on the predictors
of success for adult day programs from a marketing, financing, and programming perspective;
the challenges of operating a successful adult day program, particularly the insufficiency of
public reimbursement rates to cover the costs of running a program; and the status of adult day
programs across the State. During this meeting, Suzi Kennedy from the Life Enrichment Center
of Cleveland County, Inc. spoke about the challenges of operating a successful adult day
program and presented her menu for success at the Life Enrichment Center. Ms. Kennedy stated
that, "Without financial stability there can be no social good," and she pointed out that public
reimbursement rates are often insufficient to cover the costs of running a program.
Based on a survey conducted by the North Carolina Adult Day Services Association, in
conjunction with the Division of Aging and Adult Services, the average cost to operate an adult
day program in North Carolina is $31.00 per day for social models and $44.00 per day for health
models. Rates established by the Social Services Commission, effective December 8, 1997,
provided the maximum reimbursement rate for the purchase of adult day services at $565 per
month ($26.07 per day). Of this amount, $500 per month ($23.07) is for daily care and $65 per
month ($3.00 per day) is for round trip transportation. The maximum reimbursement rate for the
purchase of adult day health services is $715 per month ($33 per day). Of this amount, $650 per
month is for daily care ($30.00 per day) and $65 per month ($3.00 per day) is for round trip
transportation. In 1999, the Division of Aging and Adult Services considered approaching the
Social Services Commission about a rate increase; however, the Division was advised that there
was little chance of a rate increase without an overall increase in the State Adult Day Care fund,
since a rate increase without a budget increase would result in a cut to services. S.L. 2003-284,
Section 10.58 required the Social Services Commission to consider adopting rules increasing the
rates for adult day centers and adult day health centers. However, any rate increase adopted by
the Commission for adult day centers and adult day health had to be implemented within existing
funds.
The Commission supports adult day and adult day health programs and understands the
important role they play in our communities. Therefore, the Commission recommends that the
General Assembly appropriate funds and require the Social Services Commission to adopt a rate
increase of no less than five dollars ($5.00) per day for adult day and adult day health services.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 26
APPENDICES
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 27
APPENDIX A
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 28
North Carolina
Demographics of Aging
NC County Range
Total population, 2002i 8,323,946 4,170 - 734,403
Projected total population, 2020ii 10,966,139 4,706 - 1,102,003
Population age 60+, 2002iii 1,338,075 858 - 84,420
Population age 85+, 20023 116,922 88 - 7,567
Baby boomers (as % of total population), 20003 27.8% 20.6% - 32.4%
Rural population for all ages (as % of total population), 2000iv 39.8% 3.9% - 100%
Persons age 65+ without HS diploma (as % of age group), 2000v 41.6% 21.0% - 61.9%
Persons age 45-64 without HS diploma ( • ), 20005 19.9% 8.7% - 36.7%
Persons age 65+ with graduate school education ( • ), 20005 5.5% 1.1% - 18.7%
Persons age 45-64 with graduate school education ( • ), 20005 8.8% 2.4% - 32.4%
Persons age 65+ with limited or no English ( • ), 2000vi 0.5% 0% - 3.8%
Grandparents raising grandchildren age less than 18, 2000vii 79,810 31 – 5,985
Veterans age 65+ (as % of age group), 2000viii 26.8% 16.2% - 37.7%
Distribution by Age1, 2 0-17 18-49 50-64 65-84 85+
Age groups, 2002 24.5% 47.6% 16.0% 10.5% 1.4%
Projection for 2020 23.1% 43.0% 18.8% 13.3% 1.7%
Growth, 2002-2020 124.3% 119.2% 155.5% 166.8% 162.4%
Distribution by Race/
Hispanic Originix White
African
American
Native
American Asian
Hispanic/
Latino
Population age 60+ (as % of age group), 2000 82.0% 16.0% 0.7% 0.5% 0.7%
Population age 45-59 ( “ ), 2000 77.2% 18.9% 1.1% 1.2% 1.7%
Healthy Aging
NC County Range
Persons age 65+ in community with 0 disabilities* (as % of age group), 2000x 54.3% 40.2% - 66.8%
Persons age 65+ in community with 1 disability* ( • ), 200010 20.6% 14.9% - 26.4%
Persons age 65+ in community with 2 or more disabilities* ( • ), 200010 25.1% 17.0% - 34.6%
* The US Census Bureau defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for
persons to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering.”
Medicare beneficiaries immunized for influenza, 2000xi 43.5% 17.2% - 63.5%
Persons age 65+ living alone ( • ), 2000xii 28.3% 21.0% - 34.6%
Long-Term Care and Aging
NC County Range
Men age 65+ in nursing homes, 2000xiii 11,207 0 – 674
Women age 65+ in nursing homes, 200013 33,630 0 – 2,445
Persons age 65+ in nursing homes per 1000, 1999xiv 42.2 25.4 – 89.1
Persons age 65+ in adult care homes per 1000, 199914 36.5 0.0 – 67.8
CAP/DA* clients age 18+ per 1000 Medicaid eligibles, 199914 36.0 8.4 – 200.0
PCS** clients age 18+ per 1000 Medicaid eligibles, 199914 57.7 0.0 – 199.1
Adult day care/health clients age 60+ served per 1000, 199914 1.0 0.0 – 5.0
In-home aides clients, age 60+ per 1000, 199914 9.9 2.0 – 51.5
Medicaid-eligible persons age 65+, SFY 2002xv 152,300 131 – 7,198
Total Medicaid expenditures for persons age 65+, SFY 200216 $1,665,538,382 $1,151,121- $79,755,555
The amount Medicaid spent on home-based care (CAP/DA,
CAP/MR, home health, and PCS) for every $100 spent in nursing
homes for clients age 60+, SFY 2002xvi
$41.5 $6.9 - $278.4
Special Assistance (SA) expenditures for persons age 60+ in adult
care homes, SFY 200216
$90,695,940 $37,987 - $4,035,646
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 29
Economic Security
NC County Range
Median household income for age group 55-64, 1999xvii $42,250 $26,582 - $62,759
Median household income for age group 65-74, 199917 $28,521 $16,335 - $41,540
Median household income for age group 75+, 199917 $19,303 $11,195 - $33,822
Poverty Age 55-64 Age 65-74 Age 75+
Persons below poverty (as % of age group), 1999 (NC) xviii 9.5% 10.5% 16.9%
Persons in 100-199% of poverty ( • ), 1999 (NC)18 12.9% 20.4% 27.1%
Social Security NC County Range
Total Social Security (SS) benefits for beneficiaries age 65+, 2000xix $722 million $0.4 – 50.7 million
SS beneficiaries age 65+ (as % of age group), 2000xx 94.8% 73.1% - 100.0%
Average monthly SS amount received by beneficiaries age 65+, 200019,20 $786 $620 - $889
Medicare/Medicaid
Medicare Part A enrollees age 65+ (as % of all enrollees), 2000xxi 77.0% 65.7% - 86.1%
Medicare/Medicaid dually eligible persons age 65+, 2001xxii 140,535 109 – 6,609
Labor Force
Persons age 45-59 in labor force* (as % of total labor force), 2000xxiii 27.7% 21.7% - 35.8%
Persons age 60-64 in labor force* ( • ), 200023 3.6% 2.5% - 6.9%
Persons age 65+ in labor force* ( • ), 200023 3.5% 2.2% - 8.8%
Persons age 65+ In labor force* (as % of age group), 200023 14.4% 8.9% - 21.1%
Unemployed persons age 65+ (as % of population age 65+ in labor
Force*), 200023
8.3% 0.0% - 40.7%
*Include both employed and job seekers
Senior-Friendly Communities
NC County Range
Homeowners age 45-64 (as % of age group), 2000xxiv 80.3% 70.9% - 89.6%
Homeowners age 65+ ( • ), 200024 82.0% 72.0% - 91.4%
Households with persons age 60+ and without complete plumbing, 2000xxv 8,184 Undisclosed – 343
Home-delivered meals served to persons age 60+ per 1000, 199914 18.6 0 – 58.5
Food Stamps
Food Stamp clients age 60+, SFY 2001xxvi 66,832 66 – 3,893
Total Food Stamp expenditures for clients age 60+, SFY 200126 $39,628,877 $23,963 - $3,177,499
Monthly Food Stamp expenditure per client age 60+, SFY 200126 $49 $35 - $68
Transportation
Householder age 55-64 without car (as % of age group), 2000xxvii 6.0% 1.0% - 15.9%
Householder age 65-74 without car ( • ), 200027 9.0% 4.0% - 22.7%
Householder age 75+ without car ( • ), 200027 21.3% 7.5% - 33.6%
Persons Providing Care Age 18-44 Age 45-64 Age 65+
Persons providing regular care for adults age 60+ (as % of age group),
2000* xxviii
14.5% 23.8% 15.7%
*Only statewide information available at present
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 30
Sources of Information
1
North Carolina State Data Center (2003). County/state population estimates; July 1, 2002; age groups-adults. Retrieved in 6/2003
from http://www.demog.state.nc.us/.
1 North Carolina State Data Center (2003). County/state population projections; April 1, 2020 county age groups; age groups-adults.
Retrieved in 6/2003 from http://www.demog.state.nc.us/.
1 US Bureau of the Census (2003). PCT12. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P2. Urban and rural (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT25. Sex by age by educational attainment for the population 18 years and over (Summary
File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P19. Age by language spoken at home by ability to speak English for the populations 5 years
and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT9. Household relationship by grandparents living with own grandchildren under 18 years by
responsibility for own grandchildren for the population 30 years and over in households (Summary File 3). Retrieved in 6/2003 from
http://www.census.gov/.
1 US Bureau of the Census (2003). P39. Sex by age by armed forces status by veteran status for the population 18 years and over
(Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P12 A, B, C, D, and H. Sex by age (Summary File 1). Retrieved in 6/2003 from
http://www.census.gov/.
1 US Bureau of the Census (2003). PCT26. Sex by age by types of disability for the civilian noninstitutionalized population 5 years
and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 Medical Review of North Carolina (2003). Influenza immunization data. Retrieved in 2/2003 from
http://www.mrnc.org/MCMED/influenza-results.asp.
1 US Bureau of the Census (2003). P11. Household type (including living alone) by relationship for the population 65 years and over
(Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT17. Group quarters population by sex by age by group quarters type (Summary File 1).
Retrieved in 6/2003 from http://www.census.gov/.
1 NC Institute of Medicine (2001). A long-term care plan for North Carolina: Final report. Appendix D: Comparisons of availability of
services.
1 NC Division of Medical Assistance (2003). Special tabulations provided for NC Division of Aging in 6/2003.
1 NC Division of Aging (2003). Expenditure data by county for Fiscal Year 2002. Retrieved 6/2003 from
http://www.dhhs.state.nc.us/aging/exp2002/coexp2002.htm.
1 US Bureau of the Census (2003). P56. Median household income in 1999 (dollars) by age of householder (Summary File 3).
Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT50. Age by ratio of income in 1999 to poverty level. (Summary File 3). Retrieved in 6/2003
from http://www.census.gov/.
1 US Social Security Administration (2003). Table 5. Amount of OASDI benefits in current-payment status, by type of benefit, by sex
of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000).
Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html.
1 US Social Security Administration (2003). Table 4. Number of OASDI beneficiaries with benefits in current-payment status, by
type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and
county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html.
1 Medical Review of North Carolina (2003). Medicare Part A Enrollees. Retrieved from in 6/2003
http://www.mrnc.org/NCMED/beneficiary.asp.
1 Medical Review of North Carolina (2003). Dually eligible beneficiaries, 2000. Retrieved from in 6/2003
http://www.mrnc.org/NCMED/beneficiary_dual2001.asp.
1 US Bureau of the Census (2003). PCT35. Age by sex by employment status for the population 16+ years. (Summary File 3).
Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). HCT8. Tenure by age of householder (Summary File 2). Retrieved in 6/2003 from
http://www.census.gov/.
1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging in 6/2003.
1 NC Division of Social Services (2002). Special tabulation as requested by the NC Division of Aging in 9/2002.
1 US Bureau of the Census (2003). P45. Tenure by vehicles available by age of householder (Summary File 3). Retrieved in
6/2003 from http://www.census.gov/.
1 NC Center for Health Statistics (2001). BRFSS-2000 survey results. Retrieved in 7/2003 from
http://www.schs.state.nc.us/SCHS/healthstats/brfss/2000/caretakr.html.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 31
APPENDIX B
North Carolina Study Commission on Aging
Recommendations
to the
2003 North Carolina General Assembly, 2003 Regular Session
Prepared by Staff for the
North Carolina Study Commission on Aging
February 9, 2004
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 33
Recommendation Status Report
North Carolina Study Commission on Aging
RECOMMENDATIONS BILLS
INTRODUCED
RESULTS
RECOMMENDATION 1
The Commission finds that the Community
Alternative Program for Disabled Adults
(CAP/DA) is the cornerstone of community-based
care for older adults and recommends
that the General Assembly fund the program
at a level sufficient to preserve the availability
of community-based services offered through
the program.
N/A
CAP/DA funds for the 02/03 fiscal year are $255,000,000, funds were increased by
approximately $61,000,000 last session.
RECOMMENDATION 2
The Commission recommends that the 2002
Session of the 2001 General Assembly direct
the Department of Health and Human
Services to study ways to establish a group
health insurance purchasing arrangement for
long-term care staff.
H 1559
S 1196
S.L. 2002-180, Sec. 5.2 (SB 98, Sec. 5.2)
Group Health Insurance for Long-Term Care Staff Study
The Department of Health and Human Services, in consultation with the Department of
Insurance, shall study ways to establish a group health insurance purchasing arrangement
for staff, including paraprofessionals, in residential and nonresidential long-term care
facilities and agencies, as described in Recommendation #22 of the Institute of Medicine's
(IOM) Long-Term Care Task Force Final Report of January 2001. The Department shall
report its findings and recommendations to the North Carolina Study Commission on Aging
on or before January 1, 2003.
RECOMMENDATION 3
The Commission recommends that the
General Assembly direct the Department of
Health and Human Services to study ways the
State can coordinate and facilitate public
access to public and private free and discount
prescription drug programs for senior
citizens.
H 1560
S 1199
S.L. 2002-180, Sec. 5.1 (SB 98, Sec. 5.1)
Prescription Drug Access/Coordination
The Department of Health and Human Services shall study ways the State can coordinate
and facilitate public access to public and private free and discount prescription drug
programs for senior citizens. In undertaking this study, the Department shall consider the
coordination and facilitation methods being implemented by other states. On or before
January 1, 2003, the Department shall report its findings and recommendations to the North
Carolina Study Commission on Aging. The report shall include the following:
(1) A description of the various coordination and facilitation methods considered.
(2) A description of the coordination and facilitation methods of other states.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 34
(3) A recommendation as to the best way to coordinate and facilitate access in this
State, which shall include the reasons for the recommendation, a fiscal analysis of
the cost of the recommendation, and whether any legislation is necessary to
implement the recommendation.
RECOMMENDATION 4
The Commission recommends the General
Assembly establish a Legislative Study
Commission on State Guardianship Laws.
H 246
S 179
No action taken on this issue.
RECOMMENDATION 5
The Commission recommends the General
Assembly pursue ways in which national
criminal record checks may be obtained and
reviewed by long-term care facilities to
effectuate State policy and to protect facility
residents.
H 1561
S 1264
S.L. 2002-180, Sec. 2.1A (SB 98, Sec. 2.1A)
Study Issues Related to Criminal History Record Checks of Employees of Long-Term
Care Providers
The Legislative Research Commission may study how federal law affects the distribution of
national criminal history record check information requested for nursing homes, home care
agencies, adult care homes, assisted living facilities, and area mental health, developmental
disabilities, and substance abuse services authorities, and the problems federal restrictions
pose for effective and efficient implementation of State-required criminal record checks.
The study may include the following:
(1) Ways in which national record checks may be obtained and reviewed for these
facilities to effectuate State policies and protections of facility residents, and the
advantages, disadvantages, and costs of various approaches to implementation.
(2) A review of ways in which national record checks are obtained by the Division of
Child Development, Department of Health and Human Services, and other State
agencies, and related costs to the State.
(3) Solutions adopted by other states to effectively and efficiently implement criminal
record check requirements, including costs to the State in implementing these
solutions.
(4) Other issues relevant to State requirements for criminal history record checks in
long-term care facilities.
For each of the topics the Legislative Research Commission decides to study, the
Commission may report its findings, together with any recommended legislation, to the
2003 General Assembly.
Summary of
Substantive Legislation
Related to Aging
North Carolina General Assembly
2003 Session
Prepared by Staff for the:
North Carolina Study Commission on Aging
February 10, 2004
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 36
Enacted Legislation
Continuing Care Retirement/Technical Changes
S.L. 2003-193 (HB 253) makes various technical changes to the statutes that regulate continuing
care retirement communities (CCRCs). These facilities provide housing and health-related services either
for life or for a period in excess of one year. CCRCs provide independent living and also offer nursing
home or adult care home level of care. Because CCRCs include contractual requirements where, for
certain fees, the facility agrees to provide health care coverage over a given period of time, they are
considered an insurance product and are regulated by the Department of Insurance under Article 64 of
Chapter 58.
The act makes the following changes to the statutes:
· Repeals an unused, and likely unusable, provision allowing for a continuing care retirement
facility that is accredited under a process approved by the Commissioner to be issued a
license based on that accreditation.
· Replaces the word "facility" with "provider" to clarify that it is the provider that operates the
facility that is responsible for meeting the various statutory requirements.
· Clarifies language governing operating reserves for continuing care retirement facilities and
providers, including:
1. Changing the wording to reflect the fact that a provider is to calculate and maintain a
separate operating reserve for each continuing care facility operated by the provider.
2. Changing the words "annual statement" to "disclosure statement."
3. Changing the words "invested cash" to "cash equivalents."
· Makes the following changes governing the rights of residents of continuing care retirement
facilities to organize:
4. Changes "registered under this Article" to "operated by a provider licensed under this
Article" in G.S. 58-64-40(a). No entity is "registered" under G.S. 58-64.
5. Makes gender neutral corrections.
6. Clarifies that the governing body of a provider must hold semi-annual meetings with the
residents of each facility operated by the provider.
· Makes various changes governing supervision, rehabilitation and liquidation of continuing
care retirement providers including:
7. Replacing the word "projected" with "forecasted".
8. Amending the statute as necessary to accommodate the fact that a provider can own or
operate more than one facility.
· Amends the provision on receiverships, to reflect the fact that the Commissioner would be
appointed as receiver for a provider not a facility.
· Replaces the word "agreements" with "contracts" for consistency of wording within Article
64.
· Removes unnecessary language to conform with the removal of the "accredited facility"
provision.
· Amends the provision, governing civil liability, to:
9. Remove the misleading words "facility, or person violating this Article" because the
provider is the entity entering into a contract for continuing care, not the facility or other
person.
10. Remove the words "or person liable" because the provider is the only entity that is
required to deliver a disclosure statement to the contracting party.
11. Remove the words "facility, or person" since payment is made to the provider, and the
provider is the entity responsible for the dissemination of the disclosure statement.
This act became effective June 12, 2003. (DJ)
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 37
Senior Cares Program Administration
S.L. 2003-284, Sec. 10.5 (HB 397, Sec. 10.5) provides that the Department of Health and Human
Services may administer the "Senior Cares" prescription drug access program approved by the Health and
Wellness Trust Fund Commission and funded from the Health and Wellness Trust Fund.
This section became effective July 1, 2003. (TM)
Effective Date of Long-Term Care Criminal Record Checks for
Employment Positions
S.L. 2003-284, Sec. 10.8E (HB 397, Sec. 10.8E) continues the suspension of the requirements of
G.S. 131E-265 for nursing homes and G.S. 131D-2 for adult care homes to conduct national criminal
history checks for certain employees until January 1, 2005. These requirements were also suspended
during the last biennium.
This section became effective July 1, 2003. (DJ)
Implement a Pilot Project for Long-Term Care Community Service
Coordination
S.L. 2003-284, Sec. 10.8F (HB 397, Sec. 10.8F) requires the Department of Health and Human
Services to implement a communications and coordination initiative to support local coordination of long-
term care, and to pilot the establishment of local lead agencies to facilitate the long-term care
coordination process at the county or regional level. The initiative must eliminate fragmentation and
barriers to information and services; provide a seamless connection among State agencies and local
entities, regardless of funding sources; and allow consumers to efficiently and effectively navigate among
long-term care services. For those counties that voluntarily participate, the local long-term care
coordination initiative must aid in the development of core services, coordinate local services, and
streamline access to services. The Department of Health and Human Services must submit an interim
report on the pilot project for local long-term care coordination to the North Carolina Study Commission
on Aging by October 1, 2004 and a final report by October 1, 2005.
The Institute of Medicine Long-Term Care Task Force found that "long-term care services are
often fragmented, duplicative, complex, and not consumer-friendly and that many counties lack needed
core long-term care services." In response to this finding, and a report presented in accordance with S.L.
2001-491, Part XXII, the North Carolina Study Commission on Aging's 2003 report to the General
Assembly and the Governor made a recommendation that the General Assembly fund a pilot project on
long-term care local lead agencies. This provision is in response to that recommendation.
This section became effective July 1, 2003. (TM)
Medicare Enrollment Required
S.L. 2003-284, Sec. 10.27 (HB 397, Sec. 10.27) directs the Department of Health and Human
Services to require Medicaid recipients who qualify for Medicare to enroll in Medicare in order to pay
medical expenses that qualify for payment under Medicare Part B. Medicare is the federally sponsored
health insurance program for persons aged 65 or older and for certain disabled persons under age 65.
Medicare Part B pays for doctors' services, outpatient hospital care, and some other medical services that
Part A does not cover, such as the services of physical and occupational therapists, and some home
health care. In order to obtain coverage under Medicare Part B, an eligible person must pay a premium.
Requiring eligible persons to enroll in Medicare will shift health care costs from the Medicaid program
(which is paid in part with State and local funds) to the Medicare program (which is paid entirely with
federal funds).
This section became effective July 1, 2003. (DJ)
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 38
Medicaid Assessment Program for Skilled Nursing Facilities
S.L. 2003-284, Sec. 10.28 (HB 397, Sec. 10.28) directs the Secretary of Health and Human
Services to implement a Medicaid assessment program for skilled nursing facilities effective October 1,
2003. The assessment program applies to skilled nursing facilities licensed under Chapter 131E of the
General Statutes and must be imposed in a manner consistent with federal regulations under 42 C.F.R.
Part 433, Subpart B. Funds realized from assessments imposed shall:
· Be used only to draw down federal Medicaid matching funds for implementing the new
reimbursement plan for nursing homes and for increasing nursing facility rates in accordance
with the plan,
· Be used to pay 100% of the nonfederal share for the new reimbursement plan for nursing
homes; and
· Not be used to supplant State funds appropriated for nursing facility services.
This section became effective July 1, 2003. (TM)
Rename North Carolina Heart Disease and Stroke Prevention Task
Force
S.L. 2003-284, Sec. 10.33B (HB 397, Sec. 10.33B) renames the North Carolina Heart Disease and
Stroke Prevention Task Force. The new name is the Justus-Warren Heart Disease and Stroke Prevention
Task Force.
This section became effective July 1, 2003. (SA)
Senior Center Outreach
S.L. 2003-284, Sec. 10.42 (HB 397, Sec. 10.42) provides that the funds appropriated to the
Department of Health and Human Services, Division of Aging, for the 2003-2005 fiscal biennium, shall be
allocated by October 1 of each fiscal year and used by the Division of Aging to enhance senior center
programs in the following ways:
· To expand the outreach capacity of senior centers to reach unserved or underserved areas;
or
· To provide start-up funds for new senior centers. However, prior to funds being allocated for
start-up funds for a new senior center, the county commissioners of the county in which the
new center will be located shall:
12. Formally endorse the need for such a center;
13. Formally agree on the sponsoring agency for the center; and
14. Make a formal commitment to use local funds to support the ongoing operation of the
center.
Additionally, State funding shall not exceed 75% of reimbursable costs.
This section became effective July 1, 2003. (TM)
Adult Care Home Model for Community-Based Services
S.L. 2003-284, Sec. 10.43 (HB 397, Sec. 10.43) requires the Department of Health and Human
Services to develop a model project for delivering community-based mental health, developmental
disabilities, and substance abuse housing and services through adult care homes that have excess
capacity. The model must be designed for implementation on a pilot basis and address the following:
· Services that will be provided by the facility or under contract with the facility, including
assistance with daily medication.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 39
· Access of clients to mental health, developmental disabilities, and substance abuse services
provided in the community, including transportation to services outside of the client's
residence in the adult care home facility.
· Physical plant additions or changes necessary to provide for independent living of residents.
· Methods for assuring quality of services, resident safety, and cost-effectiveness.
· Consistency with the Department's Olmstead plan, other policies on community-integration,
and disability plans adopted by the State.
The Department must submit a final report on the development of the model to the Senate
Appropriations Committee on Health and Human Services, the House of Representatives Appropriations
Subcommittee on Health and Human Services, and the Fiscal Research Division on or before March 1,
2004. The report shall address the following:
· Proposed time and location for implementation of the pilot.
· Proposed number of residents to be placed and services to be provided directly by the facility
or under contract with the facility.
· Method for evaluating the pilot, including services provided, on a regular basis.
· A description of the living environment for each resident and a comparison of how the living
environment compares to that of other residents in the adult care home.
· Changes to State law necessary to implement the pilot.
· Projected cost to the State for pilot and statewide implementation.
This section provides that the development of this model is in response to the State policy to
provide appropriate services to clients in the least restrictive and most appropriate environment and with
the United States Supreme Court Decision in Olmstead vs. L.C. & E.W.
This section became effective July 1, 2003. (TM)
Special Assistance In-Home Program
S.L. 2003-284, Sec. 10.51 (HB 397, Sec. 10.51) allows the Department of Health and Human
Services to use funds from the existing State-County Special Assistance for Adults budget to provide
Special Assistance payments to eligible individuals with in-home living arrangements. These payments
may be made for up to 800 individuals during the 2003-2004 fiscal year and the 2004-2005 fiscal year.
The standard monthly payment to individuals enrolled in the Special Assistance in-home program shall be
50% of the monthly payment the individual would receive, if the individual resided in an adult care home
and qualified for Special Assistance, except if a lesser payment amount is appropriate for the individual as
determined by the local case manager. For State fiscal year 2003-2004, qualified individuals shall not
receive payments at rates less than they would have been eligible to receive in State fiscal year
2002-2003. The Department must implement Special Assistance in-home eligibility policies and
procedures to assure that in-home program participants are those individuals who need and, but for the
in-home program, would seek placement in an adult care home facility; and shall include the use of a
functional assessment. This in-home option must be available to all counties on a voluntary basis; and to
the maximum extent possible, the Department shall consider geographic balance in the dispersion of
payments to individuals across the State.
The Department is required to report on or before January 1, 2004, and on or before January 1,
2005, to the cochairs of the House of Representatives Appropriations Committee, the House of
Representatives Appropriations Subcommittee on Health and Human Services, the cochairs of the Senate
Appropriations Committee, and the cochairs of the Senate Appropriations Committee on Health and
Human Services. This report shall include the following information:
· A description of cost savings that result from allowing individuals eligible for State-County
Special Assistance the option of remaining in the home.
· A complete fiscal analysis of the in-home option to include all federal, State, and local funds
expended.
· How much case management is needed and which types of individuals are most in need of
case management.
· The geographic location of individuals receiving payments under this section.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 40
· A description of the services purchased with these payments.
· A description of the income levels of individuals who receive payments under this section and
the impact on the Medicaid program.
· Findings and recommendations as to the feasibility of continuing or expanding the in-home
program.
· The level and quantity of services (including personal care services) provided to the
demonstration project participants compared to the level and quantity of services for
residents in adult care homes.
Additionally, the Department shall incorporate data collection tools designed to compare quality
of life among institutionalized versus noninstitutionalized populations (i.e., an individual's perception of
his or her own health and well-being, years of healthy life, and activity limitations). To the extent national
standards are available, the Department shall utilize those standards. These provisions are based on
recommendations from the North Carolina Study Commission on Aging.
This section became effective July 1, 2003. (TM)
State/County Special Assistance Transfer of Assets
S.L. 2003-284, Sec. 10.53 (HB 397, Sec. 10.53) codifies the provision adopted in last year's
budget providing that Supplemental Security Income (SSI) policy concerning transfer of assets and estate
recovery applies to applicants for State-county Special Assistance and repeals current codified law on the
issue. The provision also requires the Department of Health and Human Services to continue reviewing
whether policy for State-county Special Assistance should be changed to permit an assisted living facility
to accept from a family member of a resident who qualifies for State-county Special Assistance payment
for the difference in the monthly rate for room, board, and services available. The Department must
report its activities on this policy review by March 1, 2004 to the Senate Appropriations Committee on
Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and
Human Services, and the Fiscal Research Division.
This section became effective July 1, 2003. (DJ)
Social Services Commission Rules on Rate-Setting For Adult Day
Centers and Adult Day Health Centers
S.L. 2003-284, Sec. 10.58 (HB 397, Sec. 10.58) provides that the Social Services Commission
shall consider adopting rules increasing the rates for adult day centers and adult day health centers and
that any rate increase shall be implemented within existing funds.
This section became effective July 1, 2003. (TM)
Nursing Home/Medication Errors
S.L. 2003-393 (SB 1016) requires every nursing home to establish a medication management
advisory committee to advise the quality assurance committee on quality of care issues related to
pharmaceutical and medication management and use in the nursing home. The Advisory Committee will
have the following duties:
· Assess the facility's pharmaceutical management system and practices and identify areas at
high risk for medication-related errors.
· Review the facility's pharmaceutical management goals and ensure these goals are being
met.
· Review, investigate, and respond to facility incident reports and resident grievances.
· Identify goals and recommendations for the implementation of best practices.
· Develop recommendations for the establishment of a mandatory, nonpunitive, confidential
reporting system.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 41
· Develop specifications for drug dispensing and administration documentation procedures to
ensure compliance with federal and State law, including the NC Nursing Practice Act.
· Develop specifications for self-administration of drugs by qualified patients in accordance
with law.
As part of its requirement to minimize risk of medication-related error, the act requires every
nursing home quality assurance committee to undertake the following:
· Educate and make the patient and the patient's family members aware of all the medications
the patient is using.
· Increase prescription legibility.
· Minimize confusion in prescription drug labeling and packaging.
· Develop a confidential and nonpunitive process for internal reporting of actual and potential
medication-related errors.
· To the extent practicable, implement proven medication safety practices.
· Educate facility staff engaged in medication administration.
· Implement a system to accurately identify recipients before any drug is administered.
· Implement policies and procedures designed to improve accuracy in medication
administration and in documentation.
· Implement policies and procedures for the self-administration of medication.
· Investigate and analyze the frequency and root causes of general categories and specific
types of actual or potential medication-related errors.
· Develop recommendations for plans of action to correct identified deficiencies in the facility's
pharmaceutical management practices.
The act also requires nursing home to provide a minimum of one hour of education and training
in the prevention of actual or potential medication-related errors for all nonphysician personnel involved
in direct patient care.
A new statute enacted in this act requires consultant pharmacists of nursing homes to undertake
certain drug regimen reviews, make reports concerning drug irregularities, drug product defects and
adverse drug reactions, ensure proper documentation of allergies and adverse effects, and ensure that
drugs that are not specifically limited as to duration of use or number of doses are controlled by
automatic stop orders.
Finally, the act requires the Secretary of Health and Human Services to contract with a public or
private entity to develop and implement a Medication Error Quality Initiative. As part of the Initiative,
each nursing home must report annually on the nursing home's medication-related errors. The report
submitted by each nursing home would not contain information that would identify the patient, individual
reporting the error, or other persons involved in the occurrence. The contracting entity would analyze
the reports to determine trends in the incidence of medication-related errors in nursing homes.
Information released to the contractor would retain its confidentiality and would not be subject to
discovery or use in any civil action as provided under the act.
This act becomes effective January 1, 2004. (DJ)
Audit of CAP/DA Programs by State Auditor
S.L. 2003-284, Sec. 10.29B (HB 397, Sec. 10.29B) directs the State Auditor to perform an audit
of the Community Alternatives Program for Disabled Adults (CAP/DA), provided that State funds are
appropriated for this purpose. The audit shall build upon the results of the study conducted by the North
Carolina Institute of Medicine, in accordance with Section 10.16(c) of S.L. 2002-126, and provide
information necessary to determine whether CAP/DA is operating within waiver guidelines and program
goals. The State Auditor shall report the results of the audit to the North Carolina Study Commission on
Aging by January 1, 2004.
This section also directs the Department of Health and Human Services to review, on a pilot
basis, a selected number of CAP/DA programs to determine compliance with eligibility requirements for
the program. Additionally, the Department shall continue to examine aspects of CAP/DA including: the
current assessment process; an analysis of per-client costs in CAP/DA to per-client costs in nursing
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 42
homes and adult care homes; per-participant costs for the State-County In-Home Program; an analysis of
per-person costs for personal care services through Medicaid; the monitoring of quality of care for
CAP/DA clients; the current waiting list procedures. The Department is required to make a report of its
findings to the North Carolina Study Commission on Aging by January 1, 2004.
This section became effective July 1, 2003. (TM)
Staff Contributing to this publication: Sandra Alley (SA), Dianna Jessup (DJ), and Theresa Matula (TM).
North Carolina Study Commission on Aging
Report to the Governor and the 2003 Session of the 2003 General Assembly
43
Studies and Reports Related to Aging
Study/Report Entities Involved Reporting Date Reference
Report on the pilot project for local long-term care
coordination.
DHHS to Aging Study
Commission
Interim report
10/1/04
Final report 10/1/05
S.L. 2003-284 (HB
397), Sec. 10.8.F.(b)
Report on examination of CAP/DA that includes certain
cost comparisons
DHHS to Aging Study
Commission
1/1/04 S.L. 2003-284 (HB
397), Sec. 10.29B.
Report on development of the adult care home model for
community-based services
DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB
397), Sec. 10.43.(b)
Report on the Special Assistance In-Home Demonstration
Program
DHHS to HHS 1/1/04 and 1/1/05 S.L. 2003-284 (HB
397), Sec. 10.51(b)
DHHS to review whether policy for Special Assistance
should be changed to permit an assisted living facility to
accept from a family member of a resident who qualifies
for the program payment for the difference in the monthly
rate.
DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB
397), Sec. 10.53(c)
DHHS to review activities and costs related to the
provision of care in adult care homes and determine what
costs may be considered to properly maximize allowable
reimbursement available through Medicaid and may
transfer funds from DSS to DMA to draw down federal
Medicaid funds.
DHHS to HHS and FRD As funds are
transferred and rates
are modified
Abbreviations:
DHHS: the Department of Health & Human Services
FRD: Fiscal Research Division
HHS: House of Representatives Appropriations Subcommittee on Health and Human Services & Senate Appropriations Committee on Health and Human Services
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 44
APPENDIX C
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly
45
Overview of Aging Services &
State Aging Plan
N.C.G.S. 143B-181.1A
prepared by
Division of Aging, N.C. Department of
Health and Human Services
for the
Study Commission on Aging
NC Division of Aging 2
The Aging of North Carolina—
General Organization of Plan
¡ Aging NC
¡ Healthy Aging
¡ Long-Term Care and Aging
¡ Economic Security
¡ Senior-Friendly Communities
�� Priorities of Senior Advocates
¡ State Agencies Major Activities and
Future Directions
NC Division of Aging 3
Actual and Projected Population Age 65 and Older,
North Carolina, 1940 t

NORTH CAROLINA
STUDY COMMISSION ON AGING
REPORT TO THE
GOVERNOR AND THE 2004 REGULAR SESSION OF THE
2003 GENERAL ASSEMBLY
A LIMITED NUMBER OF COPIES OF THIS REPORT IS AVAILABLE
FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY.
ROOMS 2126, 2226
STATE LEGISLATIVE BUILDING
RALEIGH, NORTH CAROLINA 27611
TELEPHONE: (919) 733-7778
OR
ROOM 500
LEGISLATIVE OFFICE BUILDING
RALEIGH, NORTH CAROLINA 27603-5925
TELEPHONE: (919) 733-9390
North Carolina
Study Commission On Aging
April 27, 2004
To: Governor Michael Easley
Lieutenant Governor Beverly Perdue, President of the North Carolina Senate
Senator Marc Basnight, President Pro Tempore of the North Carolina Senate
Representative James Black, Speaker of the North Carolina House of Representatives
Representative Richard Morgan, Speaker of the North Carolina House of Representatives
Members of the 2003 General Assembly, Regular Session 2004
Attached is a report from the North Carolina Study Commission on Aging submitted to you
pursuant to North Carolina General Statute §120-187. The North Carolina Study Commission on
Aging presents to you findings and recommendations based on study conducted after the
adjournment of the 2003 Regular Session of the 2003 General Assembly. Proposed legislation is
contained within this report.
Respectfully submitted,
___________________________ ___________________________
Senator A.B. Swindell, IV Representative Debbie A. Clary
Co-Chair Co-Chair
___________________________
Representative Edd Nye
Co-Chair
i
North Carolina Study Commission On Aging
2004 Membership List
President Pro Tempore's Appointments Speakers' Appointments
Senator Albin B. Swindell IV, Co-Chair Representative Debbie A. Clary, Co-Chair
Senator Austin M. Allran Representative Edd Nye, Co-Chair
Senator Charlie S. Dannelly Representative David R. Lewis
Senator Tony P. Moore Representative Jennifer Weiss
Senator Joe Sam Queen Representative William Eugene Wilson
Mr. Brad Allen Ms. Katherine Fox Price
Ms. Jan Elliot Ms. Florence Gray Soltys
Mr. Sam Marsh Ms. Linda Howard
Ex Officio:
Mr. Jackie Sheppard, Assistant Secretary,
Long Term Care and Family Services,
Department of Health and Human Services
Clerk:
Jo Bobbitt
919/733-5477
Staff:
Theresa Matula
Dianna Jessup
Research Division
919/733-2578
Susan Morgan
Fiscal Research Division
919/733-4910
ii
North Carolina Study Commission on Aging 1
Report to the Governor and the 2004 Session of the 2003 General Assembly
TABLE OF CONTENTS
LETTER OF TRANSMITTAL ................................................................................................. i
MEMBERSHIP LIST ................................................................................................................ ii
PREFACE ................................................................................................................................. 4
EXECUTIVE SUMMARY......................................................................................................... 5
OLDER ADULTS IN NORTH CAROLINA: A PROFILE .................................................... 7
COMMISSION PROCEEDINGS.............................................................................................. 11
COMMISSION RECOMMENDATIONS................................................................................. 16
APPENDICES
APPENDIX A ............................................................................................................................. 27
North Carolina Demographics of Aging
APPENDIX B ............................................................................................................................ 31
Commission Recommendations to 2003 General Assembly, 2003 Regular Session
Summary of Substantive Legislation Related to Aging, 2003 Session
Studies and Reports Related to Aging
APPENDIX C ............................................................................................................................ 44
Overview of Aging Services and the State Aging Plan Presentation
APPENDIX D ............................................................................................................................ 48
Guardianship Reform in the Twenty-First Century
APPENDIX E ............................................................................................................................. 53
Tax Treatment of Long-Term Care Insurance in Selected States
Long-Term Care Credits Claimed for TY 2002
AAHP-HIAA State Tax Incentives for Purchase of LTCI
APPENDIX F.............................................................................................................................. 58
Mentally Ill Population in Adult Care Homes In NC
Geriatric Mental Health Specialty Teams Presentation
Geriatric Mental Health Specialty Team Model and Guidelines
APPENDIX G............................................................................................................................. 66
Summary of Presentations by Organizations Representing Older Adults
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 2
APPENDIX H............................................................................................................................. 72
Home and Community Care Block Grant Presentation
Facts about the Home and Community Care Block Grant
Summary of Home and Community Care Block Grant Budgeted Funding
APPENDIX I.............................................................................................................................. 85
Adult Day Services in Brief
Types of Programs and Geographic Location in North Carolina
Staffing Ratios
Adult Day Services Program Closings 2001-2003
Adult Day Services Funding Fact Sheet
APPENDIX J: LEGISLATIVE PROPOSALS ......................................................................... 95
(SWz-32) AN ACT TO REPEAL THE SUNSET ON THE LONG-TERM CARE
INSURANCE TAX CREDIT, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SHz-13) AN ACT TO PROVIDE SUPPORT AND TRAINING FOR LONG-TERM CARE
PROVIDERS CARING FOR RESIDENTS WITH MENTAL ILLNESSES, AS
RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING.
(SHz-16) AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO STUDY ISSUES RELATED TO MENTALLY ILL RESIDENTS IN
LONG-TERM CARE FACILITIES, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SWz-37) AN ACT TO ESTABLISH A PILOT PROGRAM TO CONDUCT NATIONAL
CRIMINAL HISTORY RECORD CHECKS OF PERSONS SEEKING EMPLOYMENT
TO PROVIDE DIRECT CARE IN ADULT CARE HOMES AND CONTRACT
AGENCIES OF ADULT CARE HOMES, AND TO MAKE CONFORMING CHANGES,
AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON
AGING.
(SHz-6) AN ACT TO APPROPRIATE FUNDS FOR SENIOR CENTER DEVELOPMENT
AND OUTREACH, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
(SHz-7) AN ACT TO APPROPRIATE FUNDS FOR SENIOR ADULT HOUSING, AS
RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING.
(SHz-8) AN ACT TO APPROPRIATE FUNDS FOR THE HOME AND COMMUNITY
CARE BLOCK GRANT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
(SWz-34)AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO STUDY WHETHER AN INSTITUTIONAL BIAS EXISTS IN THE
STATE'S MEDICAID PROGRAM, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
North Carolina Study Commission on Aging 3
Report to the Governor and the 2004 Session of the 2003 General Assembly
(SWz-33) AN ACT TO ESTABLISH THE LEGISLATIVE STUDY COMMISSION ON
STATE GUARDIANSHIP LAWS, AS RECOMMENDED BY THE NORTH CAROLINA
STUDY COMMISSION ON AGING.
(SHz-11) AN ACT TO APPROPRIATE FUNDS AND TO REQUIRE THE SOCIAL
SERVICES COMMISSION TO ADOPT A RATE INCREASE FOR ADULT DAY
SERVICES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY
COMMISSION ON AGING.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 4
PREFACE
As outlined in Chapter 120, Article 21 of the North Carolina General Statutes, the North
Carolina Study Commission on Aging is charged with studying and evaluating the existing
system of delivery of State services to older adults and recommending an improved system of
delivery to meet the present and future needs of older adults. The Commission consists of 17
members. Of these members, eight are appointed by the Speaker of the House of
Representatives, eight are appointed by the President Pro Tempore of the Senate, and the
Secretary of the Department of Health and Human Services or the Secretary’s designee serves as
an ex officio, non-voting member.
This report represents the work performed by the North Carolina Study Commission on Aging
from the conclusion of the 2003 Session of the 2003 General Assembly until the convening of
the 2004 Session of the 2003 General Assembly. The Study Commission on Aging met on five
occasions to study a variety of topics concerning older adults including: guardianship, a long-term
care insurance tax credit, caring for the mentally ill in long-term care facilities, prescription
drug assistance, disease management, elder care housing, the long-term care workforce, adult
day services, the Home and Community Care Block Grant, and criminal history record checks of
long-term care employees. During the course of its study, the Commission also heard
presentations by representatives from fourteen (14) organizations advocating on behalf of older
adults in North Carolina.
North Carolina Study Commission on Aging 5
Report to the Governor and the 2004 Session of the 2003 General Assembly
EXECUTIVE SUMMARY
North Carolina General Statutes Chapter 143B, Article 3, Parts 14A. and 14B. establish North
Carolina's Policy Act for the Aging, and Long-Term Care. The principles of the Policy Act for
the Aging are to effectively utilize the resources of the State, to provide a better quality of life for
senior citizens, and to assure older adults the right of choosing where and how they want to live.
The Long-Term Care policy recognizes that traditional caregivers are increasingly employed
outside the home and create a growing demand for improvement and expansion of home and
community-based long-term care services to support and complement the services provided by
informal caregivers. The long-term care policy provides that the public interest would best be
served by a broad array of long-term care services that support persons who need services in the
home or in the community whenever practicable, and that promote individual autonomy, dignity
and choice. The provision also provides that institutional care will continue to be a critical part
of the State's long-term care options and that services should promote individual dignity,
autonomy, and a home-like environment.
The current size of North Carolina's older adult population, and trends indicating that this
segment of the population will increase, indicate the importance of an intense and sustained
focus on the support systems and services that North Carolina has in place for older adults.
Study efforts undertaken during the 2003-2004 interim by the North Carolina Study Commission
on Aging, sought to evaluate the existing system of services to older adults and to recommend
improvements. In response to this study, the North Carolina Study Commission on Aging makes
the following recommendations to the Governor and the 2004 Session of the 2003 General
Assembly:
Recommendation 1
The North Carolina Study Commission on Aging recommends that the General Assembly
repeal the sunset on the Long-Term Care Insurance Tax Credit.
Recommendation 2
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to continue to provide support and
training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams;
and by standardizing criteria across the Teams and tracking utilization and expenditure
data.
Recommendation 3
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to work with long-term care
providers and advocates for the elderly and the mentally ill to study issues related to
mentally ill individuals residing in long-term care facilities.
Recommendation 4
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a pilot program to conduct national criminal history record checks of persons
seeking employment to provide direct care in adult care homes or contract agencies of
adult care homes.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 6
Recommendation 5
The North Carolina Study Commission on Aging recommends that the General Assembly
support Senior Center development and outreach, and restore funding to the 2002 level, by
appropriating $281,000 for the 2004-2005 fiscal year.
Recommendation 6
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used
for independent housing with services.
Recommendation 7
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005
fiscal year.
Recommendation 8
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to study whether the State's
Medicaid Program has a bias that favors support for individuals in institutional settings
over support for individuals living at home; and to recommend ways to alleviate this bias,
if such a bias exists.
Recommendation 9
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a Legislative Study Commission to study State guardianship laws.
Recommendation 10
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate funds and require the Social Services Commission to adopt a rate increase of
no less than five dollars ($5.00) per day for adult day and adult day health services.
North Carolina Study Commission on Aging 7
Report to the Governor and the 2004 Session of the 2003 General Assembly
OLDER ADULTS IN NORTH CAROLINA:
A PROFILE
Prepared by the Department of Health and Human Services, Division of Aging and Adult Services
Older Population Today
North Carolina ranks tenth among states in the number of persons age 65 and older and eleventh
in the size of the entire population.i The fast pace of growth of the State’s older population is
evident in a recent US Census Bureau’s release in which North Carolina was ranked fourth
nationally in the increase of the number of older persons age 65+ (47,198 in NC) between April
2000 to July 2003. Only three other states (California, Texas, and Florida) reported a greater
increase among their older populations. Even so, when combined with the equally strong growth
in other age groups, the State continues to maintain an overall healthy demographic balance
among the generations. Currently, North Carolina ranks thirty-third nationally in the percentage
of the population that is 65 years of age and older (65+).
§ North Carolina population age 65+ in 2004: 1,016,214 (12.1% of total population)
§ North Carolina population age 85+ in 2004: 118,511 (1.4% of the total population)
North Carolina is rich in diversity, but its citizens face challenges because of the disparity that
exists among all populations, including older adults. Some important differences among the
State's older adults relate to gender, marital status, race/ethnicity, residence, rurality, disability,
health status, and veteran status.
§ Gender: Older women represent 59.8% of the 65+ age group and 74.0% of the 85+ age
group.ii The higher rate of poverty among older women remains a primary issue today. For
example, women age 75+ are twice as likely to be poor as men the same age.iii
§ Marital Status: At age 65 and older, women are more than twice as likely to be unmarried as
men in their age group.iv Data show that being unmarried (widowed, divorced, separated, or
never married) increases a woman’s vulnerability to poverty. According to the Social
Security Administration, 50% of unmarried women rely on Social Security for 80% of their
income and 25% rely on Social Security as their sole source of income.v
Age 65-74 Age 75-84 Age 85+
Unmarried Women in NC 45.4% 65.8% 76.5%
Unmarried Men in NC 18.7% 25.2% 39.4%
Source: NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007
North Carolina Aging Services Plan
§ Ethnicity/Race: Altogether 18.1% of persons age 65+ are members of ethnic minority groups
in North Carolina.vi Compared to the nation as a whole, North Carolina’s population age 65+
includes a larger proportion who are African American (15.3% in NC to 8.3% nationally) and
a smaller proportion of Latinos (0.6% in NC to 4.7% nationally). American Indians, Asian
Americans, and other ethnic groups each account for 1% or less of the age group 65+. The
statistics for African American and other older adults who are minority group members, in
North Carolina as well as nationally, show both a higher poverty rate and a lower life
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 8
expectancy when compared with the white population.
65+ White Minority
Total Male Female Male Female
Below Poverty 13.2% 6.5% 12.9% 21.7% 30.3%
“Near Poor”(101-200% Poverty) 23.2% –* –* –* –*
Life Expectancy at Birth (years) 75.6 73.8 79.6 68.0 75.8
Life Expectancy at Age 65 (years) 17.1 15.4 18.9 13.8 17.8
*Information currently not available.
Source: NC Division of Public Health (2002). Healthy Life Expectancy in North Carolina, 1996-2000.
§ Residence: In North Carolina, 23.8% of all homeowners are age 65+, yet among older
homeowners, over 61,000 reported incomes for 1999 that were below poverty.vii This figure
represented 38% of the homeowners of all ages with income below poverty and exceeded the
national average of 32.7%. Among renters age 65+ who provided information, 53%, or
almost 48,000, spent more than 30% of their household income on rent. Furthermore, 5,000
North Carolina homeowners and renters age 65+ lacked complete plumbing facilities in their
homes.viii Even more disturbing news is found in the statistics of emergency shelters—where
the largest increase among the homeless between 2001 and 2002 in North Carolina were
among those 55+.ix While the total population of homeless reported by shelters increased by
5% during this period, the elder homeless grew by 71% (totaling 3,494 persons in 2002).
§ Rurality: Although the United States Census Bureau has not yet released figures specifically
for the older population residing in rural areas, it is expected to easily exceed 39.8%, the rate
for the total population.x In 2000, North Carolina's rural population (3,199,831) was almost
as large as the one in Texas (3,647,539), the state with the largest number of rural residents in
the nation. Not only was North Carolina's rural population among the largest in terms of
numbers, but the state also reported the highest proportion (39.8%) of rural population
among the 20 most populous states in the nation. While 11 other states reported higher
proportions of rural population, ranging from 40.7% to 61.8%, all of these states are much
smaller in total population than North Carolina. Thus, North Carolina is unique among more
populous states in having so large a rural contingent. A 2002 report highlights a long list of
challenges rural residents and their communities face—isolation by distance, lagging
infrastructure, sparse resources that cannot adequately support education and other public
services, and weak economic competitiveness.xi
§ Disability: In North Carolina, 45.7% of the non-institutionalized civilian population age 65+
reported having one or more disablities•47.5% of women and 43.2% of men, according to
the 2000 Census.xii The Census defines disability as “a long-lasting physical, mental, or
emotional condition. This condition can make it difficult for a person to do activities such as
walking, climbing stairs, dressing, bathing, learning, or remembering. This condition can
also impede a person from being able to go outside the home alone or to work at a job or
business.”
§ Health Status: In a statewide survey, over one third of people age 65+ say that their general
health status is fair or poor, ranging from 34.1% for white women to 49.3% for minority
women.xiii In the same survey, 18.4% (highest) of minority women and 4.4% (lowest) of
white men age 65+ said that there was a time they could not see a doctor due to medical cost.
North Carolina Study Commission on Aging 9
Report to the Governor and the 2004 Session of the 2003 General Assembly
§ Veteran Status: Of the 779,393 veterans living in North Carolina, 263,102, or 34%, were age
65 and older in 2000. Another 34% were Vietnam-era veterans (between 43 and 57 years old
in 2000). The population of veterans of the Vietnam-era contains proportionally more
disabled members than the veterans’ populations of earlier wars.xiv The Veterans
Administration cites the aging of the veterans as a major challenge to its health care system
in coming years.xv
North Carolina’s Demographic Shift
Older adults are North Carolina’s fastest growing population. By 2030, our senior population
should exceed more than 2.2 million, comprising 17.9% of total population.xvi The median age
climbs from 35.3 years in 2000 to 38.4 years in 2030.
Projected Growth of Population Age 65+ (2000 – 2030)
969,048
1,183,243
1,652,288
2,221,470
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
2000 2010 2020 2030
Year
Population Age 65+
Why This Demographic Shift
A combination of improved life expectancy and lower birth rates contributes to a society’s
“aging”. In North Carolina, as anywhere in the nation, the aging of the “Baby Boomers” (born
between 1946 and 1964) will greatly accelerate this societal aging in coming years. Another
factor in the State’s aging is migration. North Carolina ranked sixth among the states with a net
migration rate of 22.1 per 1,000 among persons age 65+, in the five-year period between 1995
and 2000. [Note: A positive net migration indicates that more older adults moved to North
Carolina than left during that time.] Along with other Sunbelt states, North Carolina remains a
popular destination for people of all ages, including seniors. Other southern states with high
positive net migration among older adults include: Florida (56.9); South Carolina (33.6); Georgia
(18.1); and Tennessee (15.2).
There are other important factors influencing the diverse experiences in demographic shifts
among the State’s 100 counties.xvii In 83 counties, the rate of increase among citizens age 65+
(22%) is expected to exceed the growth of the total population (18%).
§ Rural-to-urban migration of young adults continues to age rural counties.
§ Large metropolitan counties attract large numbers of persons from outside the State as well as
from rural counties.
§ The large metropolitan counties are experiencing greater growth among younger adults than
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 10
they are among older adults.
§ A large number of older adults with higher incomes are retiring in some western and coastal
counties.
What Are the Implications of This Shift?
The aging of the population is a national and international trend, and North Carolina, like the rest
of the world, must be prepared to reap the benefits and face the challenges of an older
population. Government faces decisions about the allocation of public resources from a tax base
that may experience slowed growth, especially in many aging rural counties. People must
consider living and caregiving arrangements in light of smaller nuclear and extended families.
The health, human service, employment, and education systems must adapt to the changing
needs and interests of seniors of today and tomorrow. The business, faith communities, and
others must identify and respond to the challenges and opportunities of these demographic shifts.
In the 2003-2007 State Aging Plan, the North Carolina Division of Aging and Adult Services
introduced a new initiative–Senior-Friendly Communities–to raise awareness of the aging of our
population and to promote the North Carolina communities becoming senior-friendly through
collaboration among citizens, agencies, organizations, and programs, in both the public and
private arenas. A senior-friendly community in North Carolina will draw on the talents and
resources of active seniors while enhancing services for those are vulnerable because of their
health, economic hardships, social isolation, or other conditions. A senior-friendly community
will bring together a wide range of issues and concerns (e.g., air quality, housing, long-term care
services, employment, enrichment opportunities) that, as a whole, affect the quality of life of
seniors and others in the community. Also, a senior-friendly community will assure stewardship
of its resources to meet the needs of today’s seniors, while helping baby boomers and younger
generations prepare for the future.
For additional information on North Carolina aging demographics, please refer to Appendix A.
Sources of Information
1 US Census Bureau (2004). Annual Estimates of the Resident Population by Selected Age Groups for the United States and
States: July 1, 2003 and April 1, 2000.
1 NC State Data Center (2004). County/State Population Estimates.
1 Institute for Research on Women & Gender (2002). Difficult Dialogues Program Consensus Report: Aging in the Twenty-first
Century.
1 US Census Bureau (2002). PCT 7 (Summary File 3).
1 US Social Security Administration (1998). Fast Facts & Figures about Social Security.
1 US Census Bureau (2003). P12 (Summary File 1).
1 US Census Bureau (2002). HCT 8 (Summary File 2).
1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging.
1 NC Office of Economic Opportunity (2002). Comparison of Beneficiary Characteristics: Emergency Shelter Grants Program
(FY 2000 and FY 2001).
1 US Census Bureau (2003). P2 (Summary File 1).
1 MDC (2002). State of the South 2002.
1 US Census Bureau (2003). PCT 26 (Summary File 3).
1 NC Department of Health and Human Services (2003). A Health Profile of Older North Carolinians.
1 US Department of Veterans’ Affairs (2002). VA History in Brief.
1 US Department of Veterans’ Affairs (2002). Data on the Socioeconomic Status of Veterans and on VA Program Usage.
1 NC State Data Center (2004). County/State Population Projections.
1 NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina
Aging Services Plan.
North Carolina Study Commission on Aging 11
Report to the Governor and the 2004 Session of the 2003 General Assembly
COMMISSION PROCEEDINGS
February 10, 2004
The North Carolina Study Commission on Aging met on Tuesday, February 10, 2004 at 10:00
a.m. in Room 643 of the Legislative Office Building. Representative Edd Nye was the presiding
Co-Chair. Following Commission member introductions and approval of the budget, Theresa
Matula, Commission staff, provided an overview of the statutory basis for the Commission and
its charge. By law, the Commission is required to study and evaluate the existing system of
delivery of State services to older adults and to recommend an improved system of delivery to
meet the present and future needs of older adults. Mrs. Matula pointed out the specific duties of
the Commission as they appear in G.S. 120-181, and the reporting requirements contained in
G.S. 120-187.
Theresa Matula and Dianna Jessup, Commission staff, reviewed the status of the Commission's
recommendations to the 2003 Session of the 2003 General Assembly and presented an overview
of other legislation of interest to older adults Appendix B.
Karen Gottovi, Director, Division of Aging and Adult Services, Department of Health and
Human Services (DHHS), presented an overview of the services available for older adults in
North Carolina Appendix C. Mrs. Gottovi also presented The Aging of North Carolina, the
2003-2007 North Carolina Aging Services Plan. The Plan was submitted to the North Carolina
General Assembly on March 1, 2003. Mrs. Gottovi pointed out that the 2003-2007 Plan builds
upon the achievements of the 1999-2003 Plan as well as three other earlier plans developed in
the 1990s (1991, 1993, and 1995) and provides a foundation for new developments. The Aging
Services Plan is required by G.S. 143B-181.1A and the federal Older American Act.
John Saxon, Professor of Public Law and Government, University of North Carolina at Chapel
Hill gave a presentation on guardianship laws. Appendix D. The presentation outlined the legal
history of guardianship reform, the current law and issues that may need to be addressed, as well
as and overview of the Uniform Guardianship and Protective Proceedings Act (UGPPA).
The North Carolina tax credit for long term care insurance expired for taxable years beginning
on or after January 1, 2004. As a result, the Commission heard from Carla Obiol with the
Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), who gave an
overview of long term care insurance. Her handouts included: A Shopper's Guide to Long-Term
Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Additionally,
Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes
Division, of the North Carolina Department of Revenue, made presentations on the tax treatment
of long-term care insurance in selected states, and on the number of long-term care tax credits
claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on
the long-term care tax credit and the Department's efforts to reduce that error rate. Some of the
Department's efforts include informing taxpayers who made errors, and working with software
vendors to improve the long-term care tax credit information in their programs.
The final item on the agenda concerned adult care home rules and caring for the mentally ill.
The Commission heard presentations from Jim Upchurch, Division of Facility Services,
Department of Health and Human Services Appendix F; Dottie Harrison, Board Member, NC
National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association of Long Term
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 12
Care Facilities. Ms. Harrison addressed the consequences of the lack of appropriate housing for
mentally ill individuals and her concerns for adequate staffing and training to care for mentally
ill individuals in long-term care facilities. Ms. Wilson mentioned the use of the Geriatric Mental
Health Specialty Teams and provided recommendations for improvement.
March 9, 2004
The North Carolina Study Commission on Aging met on Tuesday, March 9, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co-
Chair. Topics of this meeting included brief remarks by organizations advocating on behalf of
older adults in North Carolina; disease management; NC Senior Care; the new Medicare
prescription drug program; and geriatric mental health specialty teams.
The Commission heard from fifteen (15) individuals that represent, or advocate on behalf of,
older adults in North Carolina. Each representative was allowed approximately three minutes to
make a brief presentation on the issues affecting older adults in North Carolina. Staff presented
the Commission members with a Summary of Presentations by Organizations Representing
Older Adults Appendix G during the March 23, 2004 meeting. The legislative priorities/issues of
concern that were mentioned with the greatest frequency were: Access to National Criminal
Record Checks (6 responses); Restoration of the LTC Insurance Tax Credit (4 responses);
Support for and/or Restoration of Funding for the home and Community Care Block Grant
(HCCBG) (3 responses); Support for/and or Restoration of Funding for Senior Centers (3
responses); and Maintaining the Viability of the Community Alternatives Program for Disabled
Adults (CAP/DA) (3 responses) Appendix G.
Alan Dobson, Chairman of Cabarrus Community Care; Chairman of Physician Advisory Group;
and President/CEO of Cabarrus Family Medicine delivered a presentation on disease
management. Community Care of North Carolina focuses on improved quality, utilization and
cost effectiveness with thirteen (13) networks with more than 2,000 physicians and 417,000
enrollees. Dr. Dobson indicated that the primary goals of Community Care of North Carolina
are to: Improve the care of the Medicaid population while controlling costs; and to Develop
community based networks capable of managing populations. He pointed out that these goals
are achieved by making sure people get the care when they need it; increasing local provider
collaboration; obtaining quality care; implementing best practice guidelines; and managing
Medicaid costs. Key program efforts for the aged and disabled include: diabetes, poly-pharmacy
in skilled nursing facilities, poly-pharmacy for the disabled, and therapy services.
Michael Keough, from the Department of Health and Human Services, gave a presentation on
the North Carolina Senior Care program. He first gave an overview of the program, which is
designed specifically to provide assistance to North Carolina seniors (age 65 or older), diagnosed
with one of three diseases (diabetes mellitus, cardiovascular disease, and chronic obstructive
pulmonary disease); have an annual household income at or below 200% of the federal poverty
level and no other prescription drug coverage. As of March 2004, there were 32,600 enrollees,
representing all 100 counties. Outreach efforts include the distribution of 400,000 enrollment
applications and an outreach grant with the General Baptist State Convention. Mr. Keough also
presented information on the Medication Assistance Program in which 23 grantees cover 60 sites
in 60 counties. The key components of the Medication Assistance Program include: Prescription
Assistance (facilitating use of pharmaceutical manufacturers' free and low cost drug programs),
and Medication Management including pharmacist evaluation of individual senior's drug
North Carolina Study Commission on Aging 13
Report to the Governor and the 2004 Session of the 2003 General Assembly
regimens. NC Senior Care is reviewing options to coordinate coverage with the recently
enacted changes to the Medicare program.
Carla Obiol, Deputy Commissioner, Seniors' Health Insurance Information Program (SHIIP)
made a presentation to the Commission on the Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Act). Ms. Obiol gave an overview of the timetable of benefits,
information on the Medicare Prescription Drug Discount Card and the Transitional Assistance
Program, the discount card sponsor qualifications, Medicare Part D: Prescription Drug Plan
(PDP), and outreach efforts by SHIIP and the Centers for Medicare & Medicaid Services (CMS).
Provisions of the Act include a Medicare-approved Prescription Drug Discount Card, a
Transitional Assistance Program, and Medicare Advantage from 2004-2005. It is anticipated
that Medicare Part D: Prescription Drug Plan will be in place by 2006. Details are continuing to
evolve and Ms. Obiol recommended the following resources: the Medicare Program:
http://www.medicare.gov/ or http://www.cms.gov/ or 1-800-MEDICARE; and SHIIP
http://www.ncshiip.com./ (see Senior Citizens heading).
This meeting concluded with a presentation on Geriatric Mental Health Specialty Teams from
Dr. Bonnie Morell, Division of Mental Health, Developmental Disabilities and Substance Abuse
Services, Department of Health and Human Services. According to Dr. Morell, the Geriatric
Mental Health Specialty Teams were developed to provide expertise and services throughout the
State in recognition of the need for greater local capacity to address and serve the needs of older
adults with mental illness. According to information presented, "The purpose of these teams is to
increase the ability of older adults with mental illness to live successfully in their communities
by: 1) assisting with the successful reintegration of older adults into the community when they
are discharged from State psychiatric hospitals, and 2) providing holistic support services and
technical assistance to nursing homes, adult care homes, and other agencies and caregivers that
serve older adults who have mental health treatment needs and who may be at risk of psychiatric
hospitalization." Appendix F
March 23, 2004
The North Carolina Study Commission on Aging met on Tuesday, March 23, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Representative Debbie Clary was the presiding
Co-Chair. Presentation topics for this meeting were elder housing, the long-term care workforce,
adult day services, the Home and Community Care Block Grant (HCCBG), a report on CAP/DA,
and criminal history record checks.
Bob Kucab, Executive Director of the North Carolina Housing Finance Agency, spoke to the
Commission about the work of the agency. The purpose of the agency is to finance housing for
persons who are not served by the private market. The agency helps seniors by improving their
existing housing and by working to develop new apartments where seniors can have affordable
rents, good living environments, and connections to community services. While the agency is
involved in a number of projects, applications for funding exceed available capital by 3 to 1. Mr.
Kucab requested an increase in the $3 million State appropriation for the Housing Trust Fund to
aid the agency in its efforts.
Susan Harmuth from the Office of Long Term Care and Family Services, Department of Health
and Human Services (DHHS), updated the Commission on the Department's long-term care
workforce initiatives. She reported that employee turnover has been decreasing since 2000, but
it is still high. The Department is working on a variety of projects to combat this turnover. One
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 14
of these projects is The Better Jobs/Better Care Demonstration. Under this demonstration, the
State's Better Jobs/Better Care Partner Team is working to develop a uniform (and voluntary) set
of expectations and criteria for use across home care, adult care homes and nursing facilities that
relate to issues impacting the recruitment and retention of direct care workers. Major domain
areas include safe and balanced workloads, training and career advancement opportunities,
supportive workplaces, worker empowerment, peer mentoring, orientation, management support,
coaching supervision, and reward and recognition.
Following Ms. Harmuth's presentation, the Commission heard several presentations concerning
adult day and adult day health services. Nancy J. Cox, Director of Partners in Caregiving, Wake
Forest University School of Medicine, presented information concerning the predictors of
success for adult day programs from a marketing, financing, and programming perspective.
Created in 1987 by The Robert Wood Johnson Foundation, Partners in Caregiving is a national
adult day services program. The focus of Partners in Caregiving is to teach non-profit adult day
centers the principles of business and marketing to be financially self-sufficient and not rely on
grants. She presented the results of a recent national study of adult day services that showed the
need for adult day service capacity building at the State level in three areas: increased public
awareness in underutilized areas, increased availability in areas where the service is not currently
an option for caregivers, and increased knowledge at the provider level regarding predictors of
success.
Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the
challenges of operating a successful adult day program. Ms. Kennedy showed pictures of the
facilities in her area and presented the "Menu for Financial Success for the Life Enrichment
Center." This Menu included: 1) a strong Board with effective committees; 2) diversified
revenue streams (operating and non-operating); 3) a diversified population; 4) unbundling the
services (i.e. transportation, personal care services, hair care); and 5) pre-billing for enrollment
rather than attendance, for the levels of care, and for ancillary services. Ms. Kennedy stated that,
"Without financial stability there can be no social good," and she pointed out that public
reimbursement rates are often insufficient to cover the costs of running a program.
Steve Freedman from the Division of Aging and Adult Services, DHHS, was the final speaker on
the subject of adult day services Appendix I. Mr. Freedman stated that there are currently 113
certified adult day and adult day health programs in the State, a decrease from the peak of 125
programs in 2000. The programs are currently located in 60 counties. The Division of Aging
and Adult Services has been working with the North Carolina Adult Day Services Association to
develop fiscal training for adult day programs. According to the Division, the aim of this project
is to assist adult day programs with budgeting and help increase their understanding of service
costs. Mr. Freedman also addressed reimbursement rates. Currently, the maximum
reimbursement rate for adult day services is $26.07 per day, and $33.00 per day for adult day
health services. According to the North Carolina Adult Day Services Association, the average
cost to operate an adult day program is $31.00 per day, and for adult day health programs it is
$44.00 per day. In the 2003 budget bill, the General Assembly directed the Social Services
Commission to consider adopting rules to increase these rates within existing funds. A rate
increase has not occurred.
Next, Dennis Streets from the Division of Aging and Adult Services, DHHS presented
information concerning the Home and Community Care Block Grant Appendix H. The Home
and Community Care Block Grant (HCCBG) was established by the General Assembly in 1992.
North Carolina Study Commission on Aging 15
Report to the Governor and the 2004 Session of the 2003 General Assembly
By consolidating several funding sources (i.e. the Older Americans Act, the Social Services
Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds,
and other relevant State appropriations), the HCCBG helps to coordinate the service delivery
system to meet the needs of seniors. The focus of the HCCBG is to support the frail elderly at
home, assist with access to services and information, provide family caregiver relief and help
seniors remain active. While there have been some increases in federal funds, State support has
decreased. According to Mr. Streets, there are more than 6,500 unmet service needs, especially
for home-delivered meals and in-home aide services.
Gary Fuquay, Division of Medical Assistance, DHHS, presented a report on the Community
Alternatives Program for Disabled Adults (CAP/DA), required by S.L. 2003-284, Sec. 10.29B(b)
and (c). The section basically required the Department to conduct a cost analysis of CAP/DA
and the State/County Special Assistance In-Home program in relation to the per client cost of
nursing homes and adult care homes. While the report attempted to provide cost comparisons,
Mr. Fuquay warned that it is difficult to draw conclusions from the data because one cannot
compare level of care indicators.
The Commission next heard from various speakers concerning national criminal history records
checks of long-term care workers. John Aldridge from the North Carolina Attorney General's
Office gave an overview of current law regarding who can receive the results of national
criminal history records checks and for what purposes. Jackie Sheppard from the Office of
Long-Term Care and Family Services, DHHS, gave an overview of what the state of Mississippi
is doing to address this issue. Roger Manus, representing Friends of Residents in Long-Term
Care, urged the Commission to look at Florida's system for conducting background checks.
Stacy Flannery, representing the NC Health Care Facilities Association, presented the providers'
concerns about this issue.
Finally, the meeting concluded with a brief presentation summarizing Appendix G the
association presentations from the March 9 meeting. Chief among the issues raised by the
associations was the current moratorium on national criminal history records checks of long-term
care workers.
April 13, 2004
The North Carolina Study Commission on Aging met on Tuesday, April 13, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co-
Chair. During this meeting, the Commission heard a presentation from Jackie Franklin with the
Division of Aging and Adult Services, Department of Health and Human Services, on the
State/County Special Assistance In-Home program. The Commission discussed and initially
approved recommendations to the Governor and the General Assembly. The Commission also
directed the staff to prepare a draft report for review at the final meeting.
April 27, 2004
The North Carolina Study Commission on Aging met on Tuesday, April 27, 2004 at 10:00 a.m.
in Room 643 of the Legislative Office Building. Members discussed and approved the
Commission’s Report to the Governor and to the 2004 Session of the 2003 General Assembly.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 16
COMMISSION RECOMMENDATIONS
The North Carolina Study Commission on Aging makes the recommendations presented in this
section to the Governor and the 2004 Session of the 2003 General Assembly. Each
recommendation is followed by background information, and corresponding legislative proposals
appear in Appendix J of this report.
Recommendation 1
The North Carolina Study Commission on Aging recommends that the General Assembly
repeal the sunset on the Long-Term Care Insurance Tax Credit.
Background
In 1997, the North Carolina Study Commission on Aging recommended that the 1997 General
Assembly enact a 15% tax credit, up to a maximum of $350, on the premiums paid by the
purchaser of long-term care insurance policies. According to the 1997 Commission report, the
Office of State Budget and Management estimated that a 15% tax credit up to a maximum of
$350 may result in a revenue loss of $17 million. The report further stated that, the average
premium was $1,600, thus a 15% credit would be equal to $240. The report acknowledged that
it was difficult to estimate the offsetting benefits of the tax credit in terms of reduced Medicaid
payments, but that the cost of a year's stay in a North Carolina nursing home was $40,000. The
Commission recommended this tax credit again in 1998, and the credit became Section 29A.6 of
Session Law 1998-212. The tax credit was effective for taxable years beginning on or after
January 1, 1999, and expired for taxable years beginning on or after January 1, 2004.
On January 16, 2003, the Department of Revenue prepared a memorandum for the Revenue
Laws Study Committee on the status of the tax credit for premiums paid on long-term care
insurance. The memorandum outlined the Department's review of some of the returns on which
the credit was claimed. During this review, auditors found that some taxpayers, who were not
eligible for the tax credits, claimed the tax credits; and that some taxpayers claimed long-term
care credits greater than the cap of $350. The Department found that, "Of the 2,155 returns
reviewed, only 192 contained allowable long-term care credits. Taxpayers were not eligible for
the credits claimed on the remaining 1,963 returns in this group. As a group, therefore, over
90% of the returns incorrectly claimed the credit." Because this represented a sample, the
Department indicated that they did not know the error rate for all returns claiming the credit.
They attributed the high error rate to two possible factors: "One factor is the complicated nature
of the credit and the other is confusion of this credit with the repealed child health insurance
credit." Additionally, the memorandum indicated that, for tax year 2001, the credit reduced tax
revenue by $10,367,883.
The 2003 North Carolina Study Commission on Aging recommended repealing the sunset on the
long-term care insurance tax credit. In its 2003 report, the Commission expressed agreement
with a statement from a Division of Aging's report, Increasing Personal Responsibility for Long
Term Care through Private Long Term Care Insurance. The Division's report stated that, "In
addition to the public benefit of having a much larger segment of the adult population positioned
to pay privately for long-term care in terms of the state's economic health, consumers and
families benefit from the ability to pay privately through increased choice and flexibility in terms
of the range of services and settings of care available." S.L. 1998-212, Section 29A.6(d) made
North Carolina Study Commission on Aging 17
Report to the Governor and the 2004 Session of the 2003 General Assembly
the credit for premiums paid on long-term care insurance effective for taxable years beginning on
or after January 1, 1999, and sunset the credit effective January 1, 2004. The Commission's bills
repealing the sunset were introduced during the 2003 Session, but were not successful and the
tax credit was allowed to sunset. As a result, the tax credit is not currently in place for the 2004
tax year.
During the February 10, 2004 meeting, the Commission heard a presentation on long-term care
insurance from Carla Obiol with the Seniors' Health Insurance Information Program (SHIIP),
and presentations on issues related to the tax credit from Department of Revenue employees Karl
Knapp, Tax Research Division, and Nancy Pomeranz, Personal Taxes Division Appendix E.
Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program
(SHIIP), gave an overview of long-term care insurance. Her handouts included: A Shopper's
Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North
Carolina . Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal
Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax
treatment of long-term care insurance in selected states, and on the number of long-term care tax
credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate
experienced on the long-term care tax credit and the Department's efforts to reduce that error
rate. The Department indicated that they had made progress in reducing the error rate on the
long-term care insurance tax credit. Commission staff also obtained a chart Appendix E from the
American Association of Health Plans-Health Insurance Association of America (AAHP-HIAA)
depicting those states in the United States that offer tax incentives for the purchase of long-term
care insurance. AAHP-HIAA is a national trade association representing the private sector in
health care. The chart from AAHP-HIAA shows that 6 states offer tax credits and 16 states offer
tax deductions. (Note: The information in the AAHP-HIAA chart does vary from the Department
of Revenue's information, which could be the result of different compilation dates.)
According to information received by the Commission staff, on June 5, 2003, the Department of
Revenue reported that they had audited 2,372 returns for the tax year 2002, and adjusted 650 to
disallow the credit, representing a 27% error rate. This error rate was down considerably from
the 90% error rate on the 2001 returns reported earlier by the Department. The Department
attributed the decrease to: 1) informing tax preparers of the appropriate use of the credit; 2)
clarifying instructions about eligibility for the credit; 3) improving the verbiage in software
developers' tax packages; and 4) communicating with taxpayers whose credit was disallowed in
2001, to inform them of the eligibility criteria for the tax credit. An additional $279,628 was
assessed on the 650 returns adjusted, and returns continue to be audited as resources permit. On
November 3, 2003, the Department reported that they had processed 3,574,530 returns:
2,158,850 paper and 1,415,680 efiled. Of the total, there were 35,936 on which a credit for long-term
care insurance was claimed for a total of $19,110,623.
The North Carolina Study Commission on Aging has supported the long-term care insurance tax
credit since its inception and the current Commission continues to support it. The Commission
scheduled presentations on this issue at the first meeting this interim, and restoration of the long-term
care insurance tax credit was an item mentioned frequently during presentations on March
9, 2004, by organizations representing older adults in North Carolina. The Commission
recommends that the General Assembly repeal the sunset on the long-term care insurance tax
credit.
Recommendation 2
The North Carolina Study Commission on Aging recommends that the General Assembly
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 18
require the Department of Health and Human Services to continue to provide support and
training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams;
and by standardizing criteria across the Teams and tracking utilization and expenditure
data.
Background
On February 10, 2004, the Commission heard presentations on adult care home rules and caring
for the mentally ill from Jim Upchurch, Division of Facility Services, Department of Health and
Human Services (DHHS); Dottie Harrison, Board Member, NC National Alliance for the
Mentally Ill (NAMI); and Lou Wilson, NC Association Long Term Care Facilities. On March 9,
2004, the Commission heard a presentation on Geriatric Mental Health Specialty Teams from
Bonnie Morell, Community Policy Section, Division of Mental Health, Developmental
Disabilities and Substance Abuse Services, Department of Health and Human Services (DHHS).
Appendix F
During her presentation, Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty
Teams. She indicated that while the intent of the program was positive, she believed, "The State
has provided very little guidance for area mental health programs as to how the teams should be
operated, thus the program has floundered in many areas of the state." She also stated that,
"Area programs all over the State have developed criteria, protocol, policies and procedures that
are unique to their area program. As a result, consumers and providers of services are expected
to muddle through a system of inconsistency."
According to information provided by DHHS, Geriatric Mental Health Specialty Teams were
developed to increase the ability of older adults with mental illness to live successfully in their
communities by: 1) assisting with the successful reintegration of older adults into the community
when they are discharged from State psychiatric hospitals; and 2) providing holistic support
services and technical assistance to nursing homes, adult care homes, and other agencies and
caregivers that serve older adults who have mental health treatment needs and who may be at
risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who
are preparing to enter a nursing home or an adult care home, who currently reside in a nursing
home or adult care home, and who are living in their own home or with family members.
Individuals with geriatric-like needs are also served. Dr. Morell noted that, "This is a fairly new
program that is being implemented during a time of change in the public mental health system.
Focus will be on identifying ways in which to support the work that is being done by the teams
that have been put in place."
During her presentation on February 10, 2004, Ms. Wilson shared a recommendation for
legislation. Ms. Wilson's recommendations include: 1) renaming the Teams to Long Term Care
Facility Specialty Teams; 2) requiring all licensed adult care homes and nursing homes that serve
individuals with a mental illness to participate in the program; 3) deleting the age requirement
and the restrictions for residents to be at risk of psychiatric hospitalization and making services
available for all persons with a mental illness who reside in adult care homes and nursing homes;
4) increasing the number of professionals on each team and/or decreasing the geographic areas
that each team covers; 5) developing standardized criteria; 6) fully funding the program to
support the individuals and facilities eligible for services; and 7) repealing the current adult care
home special unit rule for persons with mental illnesses and create a new licensure law and rules
that are more realistic.
North Carolina Study Commission on Aging 19
Report to the Governor and the 2004 Session of the 2003 General Assembly
According to information provided by staff in the General Assembly's Fiscal Research Division,
the Geriatric Mental Health Specialty Teams are a contracted service through the Local
Management Entities (LME). There are 20 Teams across North Carolina and each one contracts
with one or more LME's. These are funded with Mental Health Trust Fund dollars, and these
non-recurring funds are being replaced by recurring funds made available through mental
hospital downsizing. As a Team delivers services to a facility, they file for reimbursement with
the LME, which in turn seeks reimbursement from DHHS. Currently, DHHS cannot report
specific cost data on the Geriatric Mental Health Specialty Teams.
Based on the information presented to the Commission, the Commission recommends that the
General Assembly require the Department of Health and Human Services to continue to provide
support and training for long-term care providers caring for residents with mental illnesses by
conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and
by standardizing criteria across the Teams and tracking utilization and expenditure data.
Recommendation 3
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to work with long-term care
providers and advocates for the elderly and the mentally ill to study issues related to
mentally ill individuals residing in long-term care facilities.
Background
On February 10, 2004, the Commission heard presentations concerning caring for mentally ill
individuals in long-term care facilities. One of the presenters was Dottie Harrison, Board
Member, NC National Alliance for the Mentally Ill (NAMI). Ms. Harrison questioned whether
adult care homes were appropriate housing options for mentally ill individuals, and she
questioned the appropriateness of staffing and training at these facilities. Specifically, Ms.
Harrison supported training on the appropriate administration of psychiatric medications, and
training on appropriate interaction with residents based on their particular mental illness.
Another presenter at the February meeting, Lou Wilson, Executive Director of the North
Carolina Association of Long Term Care Facilities, stated that adult care home providers,
"simply do not know how to muddle through the complex mental health systems, develop good
rapports with mental health providers, provide mental health training for staff and recognize
issues when specific residents are having difficulty." Ms. Wilson requested training for adult care
home staff that will enable them to recognize symptoms of mental illness and urged the State,
advocates, and the industry, to work together to ensure that individuals with mental illnesses
receive the services they are entitled to receive.
During the March 9, 2004 meeting, Dr. Bonnie Morell shared information with the Commission
on the Geriatric Mental Health Specialty Teams Appendix F. One of the purposes of these
Teams is to provide support services and technical assistance to nursing homes, adult care
homes, and other agencies and caregivers that serve older adults who have mental health
treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams
serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care
home, who currently reside in a nursing home or adult care home, and who are living in their
own home or with family members. Individuals with geriatric-like needs are also served.
In addition to other recommendations, Lou Wilson also requested the creation of a new licensure
law and rules that are more realistic. During discussions at the April 13, 2004 meeting,
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 20
Commission members voiced support for examining whether current State statutes and
Departmental rules adequately address the populations served by long-term care facilities. They
also supported examining adult care home rules to determine whether they are easy to
understand, attainable under current staffing patterns, give appropriate guidance to facility
operators according to the needs and characteristics of residents served, support resident's
freedom of choice, and whether they support the autonomy, dignity and independence
philosophy of assisted living.
The Commission supports quality care for mentally ill individuals and elderly individuals and
recommends that the General Assembly require the Department of Health and Human Services
to work with long-term care providers and advocates for the elderly and the mentally ill to study
issues related to mentally ill individuals residing in long-term care facilities.
Recommendation 4
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a pilot program to conduct national criminal history record checks of persons
seeking employment to provide direct care in adult care homes or contract agencies of
adult care homes.
Background
State law currently requires criminal history record checks of all applicants for employment with
nursing homes, home health care agencies, and adult care homes. If the applicant has been a
resident of North Carolina for less than five years, the criminal history record check must include
both a national and a State criminal history record check. If the applicant has been a resident of
North Carolina for five years or more, only a State criminal history record check is required.
However, under federal law, the FBI may release results of national criminal history checks
directly to nursing homes and home health care agencies on applicants for positions that involve
direct patient care. Otherwise, results of criminal history checks performed by the FBI can only
be released to a state agency and cannot be released directly to a provider. This has made it
difficult for providers to comply with State law. As a result, a moratorium on national criminal
history record checks was instituted in S.L. 2002-126, Sec. 10.10C for applicants for positions in
nursing homes and home care agencies other than those involving direct patient care and for
applicants for all staff positions in adult care homes, until January 1, 2004. Session Law 2003-
284, Sec. 10.8E extended the moratorium to January 1, 2005.
Access to national criminal history record checks was an item mentioned frequently during
presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older
adults in North Carolina. On March 23, 2004, the Commission heard a presentation from John
Aldridge of the North Carolina Attorney General's office on this issue. He reiterated that unless
federal law provides otherwise, the results of a national criminal history record check can only be
released to a governmental agency. Currently, federal law only permits these results to be
released to nursing homes and home care agencies on applicants for positions that involve direct
patient care. Therefore, in order to be able to conduct national criminal history record checks on
applicants for positions in nursing homes and home care agencies that do not involve patient care
and on applicants for positions in adult care homes, current State law would have to be changed
to direct that the results be sent to a governmental agency.
The Commission recognizes that long-term care advocates and providers have legitimate
concerns about the current status of national criminal history record checks. Roger Manus,
North Carolina Study Commission on Aging 21
Report to the Governor and the 2004 Session of the 2003 General Assembly
President of Friends of Residents in Long Term Care, pointed out during the Commission's
meeting on March 23, that people living in long-term care facilities are the vulnerable frail
elderly and disabled that cannot defend themselves, and many cannot communicate when they
perceive a threat. Worst of all, they spend the night in these facilities when staffing levels
decrease even further with greater potential and opportunity for abuse. It is important to ensure
the safety of this vulnerable population. On the other hand, the Commission recognizes that
employee turnover is high in long-term care facilities. It is important that providers be able to
fill positions quickly and not have to wait an inordinate amount of time for a determination to be
made by an agency about whether an applicant is disqualified because of the applicant's criminal
background. Questions arose during the Commission's deliberations about the State's
technological and staffing capacity to be able to turn around a determination of disqualification
quickly.
The Commission recommends moving this issue forward by establishing a pilot program to
conduct national criminal history record checks of workers in adult care homes and contract
agencies of adult care homes who provide direct resident care and requiring the Department of
Health and Human Services to collect information and meet regularly with providers and others
to monitor the progress of the pilot to determine what is needed in order to fully implement the
national criminal history record checks as the General Assembly intended.
Recommendation 5
The North Carolina Study Commission on Aging recommends that the General Assembly
support Senior Center development and outreach, and restore funding to the 2002 level, by
appropriating $281,000 for the 2004-2005 fiscal year.
Background
Senior Centers are resources within communities that typically provide nutrition, recreation,
social and educational services, and comprehensive information and referral. The National
Institute of Senior Centers defines a senior center as a place where “older adults come together
for services and activities that reflect their experience and skills, respond to their diverse needs
and interests, enhance their dignity, support their independence, and encourage their involvement
in and with the center and the community.” Prior to the 2002 Session, State funds for Senior
Centers were $1,365,316. During the 2002 Session, funds were reduced by $381,000. During the
2003 Session, $100,000 was restored, and the local match requirement was increased.
Support for and/or restoration of funding for Senior Centers was an item mentioned frequently
during presentations on March 9, 2004, by organizations representing, or advocating on behalf
of, older adults in North Carolina Appendix G. To fully restore State funding to the prior level,
an additional $281,000 would be needed. Therefore, the Commission recommends that the
General Assembly support Senior Center development and outreach, and restore funding to the
2002 level, by appropriating $281,000 for the 2004-2005 fiscal year.
Recommendation 6
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used
for independent housing with services.
Background
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 22
The Housing Finance Agency mission is to create affordable housing opportunities for North
Carolinians whose needs are not met by the market. This mission is accomplished through
helping older individuals age in place by improving existing housing, and by working to develop
new apartments for older adults. In the March 23, 2004 presentation, Bob Kucab, Executive
Director, stated that applications for funding requests currently exceed available capital by 3:1.
State funds help bring in outside funding because the Housing Finance Agency is able to
leverage $5 in development from every $1 the State invests. According to Mr. Kucab, all State
funds that they administer are invested in bricks and mortar; staff costs are paid from their
revenue. Mr. Kucab reported that, State appropriations are currently down to $3 million from a
high of $9 million.
The Commission recognizes the need for new apartments with affordable rent, where older
adults can enjoy safe and comfortable living environments, and connections to community
services. Therefore, the Commission recommends that the General Assembly appropriate
$1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent
housing with services.
Recommendation 7
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005
fiscal year.
Background
On March 23, 2004, Dennis Streets, Division of Aging and Adult Services, DHHS, made a
presentation to the Commission on the Home and Community Care Block Grant (HCCBG)
Appendix H. His presentation gave an overview of the program; eligibility criteria; and
information on program utilization, availability, and needs. The HCCBG is established by G.S.
143B-181.1(a)(11). Mr. Streets pointed out that by "consolidating several funding sources (i.e.,
the Older Americans Act, the Social Services Block Grant in support of respite care, portions of
the State In-Home and Adult Day Care funds, and other relevant State appropriations)—some of
which traditionally went to separate organizations—the HCCBG represented an important step
toward establishing a well coordinated service delivery system to meet the needs of a rapidly
growing older population." The HCCBG includes federal funds, State funds, local funds, and a
client cost sharing component. The two principal purposes of the HCCBG are to give counties
greater discretion, flexibility and authority in determining services, service levels and service
providers; and to streamline and simplify the administration of services. The HCCBG focuses
on: supporting frail elderly in their preference to be cared for at home; improving and
maintaining the physical and mental health of older adults; assisting older adults and their
caregivers with accessing services and information; providing relief to family caregivers so that
they can continue their caregiving; and allowing older adults to remain actively engaged with
their communities.
Any person age 60 and older is eligible for services under the HCCBG. The HCCBG program
places an emphasis on reaching those most in need of services (the Older Americans Act (OAA)
gives priority to serving the "socially and economically needy" -with particular attention to low-income
minority elderly and older individuals residing in rural areas). Additionally, the OAA
calls for reaching out to older individuals with severe disabilities, limited English-speaking
ability, and Alzheimer's disease or related disorders (and caregivers of these individuals).
North Carolina Study Commission on Aging 23
Report to the Governor and the 2004 Session of the 2003 General Assembly
State appropriations for the HCCBG were $25,128,469 for the 2002-2003 fiscal year. State
appropriations were cut by $1,055,690 to $24,072,799 for the 2003-2004 fiscal year. State
appropriations are currently slated to be reduced to $24,026,079 for the 2004-2005 fiscal year.
An increase in federal Older Americans Act funds has helped to offset the decrease in State
funding and overall funding of the program was down from the previous year only $341,603 for
2003-2004. However, the Division anticipates a decrease in federal funding for 2004-2005,
which would leave the overall total down another $389,974. Unless the General Assembly
increases State appropriations, the total net funding for HCCBG would be down $731,577 for the
period from 2002-2003 to 2004-2005.
Support for and/or restoration of funding for the HCCBG was an item mentioned frequently
during presentations on March 9, 2004, by organizations representing, or advocating on behalf
of, older adults in North Carolina Appendix G. The Commission recognizes the vital services
that are provided under the HCCBG and recommends that the General Assembly appropriate
$1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year.
Recommendation 8
The North Carolina Study Commission on Aging recommends that the General Assembly
require the Department of Health and Human Services to study whether the State's
Medicaid Program has a bias that favors support for individuals in institutional settings
over support for individuals living at home; and to recommend ways to alleviate this bias,
if such a bias exists.
Background
The Final Report by The North Carolina Institute of Medicine Task Force on Long-Term Care
reported an institutional bias in Medicaid eligibility rules. The report states that a reason public
funding is weighted toward institutional care is that Medicaid and other public program rules
make it easier for people to qualify for financial assistance with institutional or residential care
than for services provided at home or in the community. Under existing laws, individuals can
qualify for either nursing home care or State-County Special Assistance for adult care homes
with higher monthly incomes than they can if they want to obtain Medicaid coverage for health
services provided in their own home. With these different income eligibility limits, individuals
living at home who may have too much income to qualify for Medicaid coverage as long as they
remain in their home, may qualify if they move into a more costly institutional or residential
setting.
In Olmstead v. L.C., the United States Supreme Court concluded that inappropriate
institutionalization of a person with a mental disability may be discrimination under ADA. The
Commission recognizes that the law favors caring for an individual in the community rather than
in an institution, and institutional care may be more costly than residential care. Therefore, the
Commission recommends that the General Assembly direct the Department of Health and
Human Services to study whether an institutional bias in Medicaid eligibility rules do in fact
exist and if they do exist, to determine how to alleviate the bias.
Recommendation 9
The North Carolina Study Commission on Aging recommends that the General Assembly
establish a Legislative Study Commission to study State guardianship laws.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 24
Background
Guardianship is a legal relationship in which a person or agency (the guardian) is appointed by a
court to make decisions and act on behalf of another person (the ward) with respect to the ward’s
personal or financial affairs because the ward, due to a specific mental or physical impairment,
lacks sufficient capacity to make or communicate important decisions concerning his or her
person, family, or property or lacks sufficient capacity to manage his or her personal or financial
affairs. Laws regarding guardianship for incapacitated adults attempt to strike a balance between
preserving the legal rights, freedom, and autonomy of individuals vs. society’s duty (parens
patriae) to protect individuals who are unable to protect or care for themselves.
On February 10, 2004, the Commission heard a presentation on "Guardianship Reform in the
Twenty-First Century" Appendix D by John Saxon, Professor of Public Law and Government,
UNC Chapel Hill. According to his presentation, the last substantive revision to the guardianship
law was in 1977, and the last consolidation and clarification was enacted in 1987. Since 1987,
there have been efforts to review and revise the statutes, but none resulted in change. Current
law consists of an assortment of statutes, some of which date back to the 1800s. As a result,
there are a number of issues in the guardianship statutes that need review and updating, including
interstate jurisdiction, the definition and standard of incapacity, due process, guardianship
alternatives, limited guardianship, the guardian's powers, and the role of human service agencies.
Professor Saxon suggested that as an alternative to rewriting current law, North Carolina could
adopt the Uniform Guardianship and Protective Proceedings Act (UGPPA). The UGPPA has
been enacted in four states. The UGPPA authorizes two types of legal proceedings: guardianship
proceedings to appoint guardian (guardian of the person) for a minor or incapacitated person; and
protective proceedings regarding the property of a minor or a missing, absent, detained, or
incapacitated person, including proceedings seeking the appointment of a conservator (i.e.
guardian of the estate). Under the UGPPA, guardianship and conservatorship is viewed as last
resort. A guardian or conservator may be appointed only if there are no other lesser restrictive
alternatives that will meet the respondent’s needs, and limited guardianship or conservatorship
should be used whenever possible. According to Professor Saxon, the UGPPA is advantageous
because it is modern, comprehensive, legally adequate, balanced, proven, and could be
customized to address any issues that are unique to North Carolina.
The North Carolina Study Commission on Aging recognizes that the laws pertaining to
guardianship are important for the protection of citizens who are unable to make personal
decisions due to impairment or incapacity, and that these laws have not been thoroughly
reviewed in 17 years. Therefore, the Commission recommends the General Assembly establish a
Legislative Study Commission on State Guardianship Laws.
Recommendation 10
The North Carolina Study Commission on Aging recommends that the General Assembly
appropriate funds and require the Social Services Commission to adopt a rate increase of
no less than five dollars ($5.00) per day for adult day and adult day health services.
Background
North Carolina General Statute 131D-6 provides that adult day care enables people who would
otherwise need full-time care away from their own residences to remain in their residences as
long as possible. An adult day care program provides group care and supervision for physically
or mentally disabled adults in a place other than their usual place of abode on a less than 24-hour
North Carolina Study Commission on Aging 25
Report to the Governor and the 2004 Session of the 2003 General Assembly
basis. Adult day services include a social model and a health model. Both models provide a
community setting that promotes social interaction, and physical and emotional well-being.
Adult day health programs also offer health care services to meet the needs of individual
participants. Nutritional meals and snacks are provided and transportation to and from the
program may be provided or arranged when needed. Often these programs provide a safe
stimulating environment while a primary caregiver is at work. Providers of adult day care must
meet North Carolina State Standards for Certification. The Social Services Commission sets
these standards and the reimbursement rates paid for adult day and adult day health services.
During the March 23, 2004 meeting, the Commission heard from Nancy J. Cox, Director of
Partners in Caregiving, Wake Forest University School of Medicine; Suzi Kennedy from the Life
Enrichment Center of Cleveland County, Inc.; and Steve Freedman from the Division of Aging
and Adult Services, DHHS Appendix I. The Commission received information on the predictors
of success for adult day programs from a marketing, financing, and programming perspective;
the challenges of operating a successful adult day program, particularly the insufficiency of
public reimbursement rates to cover the costs of running a program; and the status of adult day
programs across the State. During this meeting, Suzi Kennedy from the Life Enrichment Center
of Cleveland County, Inc. spoke about the challenges of operating a successful adult day
program and presented her menu for success at the Life Enrichment Center. Ms. Kennedy stated
that, "Without financial stability there can be no social good," and she pointed out that public
reimbursement rates are often insufficient to cover the costs of running a program.
Based on a survey conducted by the North Carolina Adult Day Services Association, in
conjunction with the Division of Aging and Adult Services, the average cost to operate an adult
day program in North Carolina is $31.00 per day for social models and $44.00 per day for health
models. Rates established by the Social Services Commission, effective December 8, 1997,
provided the maximum reimbursement rate for the purchase of adult day services at $565 per
month ($26.07 per day). Of this amount, $500 per month ($23.07) is for daily care and $65 per
month ($3.00 per day) is for round trip transportation. The maximum reimbursement rate for the
purchase of adult day health services is $715 per month ($33 per day). Of this amount, $650 per
month is for daily care ($30.00 per day) and $65 per month ($3.00 per day) is for round trip
transportation. In 1999, the Division of Aging and Adult Services considered approaching the
Social Services Commission about a rate increase; however, the Division was advised that there
was little chance of a rate increase without an overall increase in the State Adult Day Care fund,
since a rate increase without a budget increase would result in a cut to services. S.L. 2003-284,
Section 10.58 required the Social Services Commission to consider adopting rules increasing the
rates for adult day centers and adult day health centers. However, any rate increase adopted by
the Commission for adult day centers and adult day health had to be implemented within existing
funds.
The Commission supports adult day and adult day health programs and understands the
important role they play in our communities. Therefore, the Commission recommends that the
General Assembly appropriate funds and require the Social Services Commission to adopt a rate
increase of no less than five dollars ($5.00) per day for adult day and adult day health services.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 26
APPENDICES
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 27
APPENDIX A
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 28
North Carolina
Demographics of Aging
NC County Range
Total population, 2002i 8,323,946 4,170 - 734,403
Projected total population, 2020ii 10,966,139 4,706 - 1,102,003
Population age 60+, 2002iii 1,338,075 858 - 84,420
Population age 85+, 20023 116,922 88 - 7,567
Baby boomers (as % of total population), 20003 27.8% 20.6% - 32.4%
Rural population for all ages (as % of total population), 2000iv 39.8% 3.9% - 100%
Persons age 65+ without HS diploma (as % of age group), 2000v 41.6% 21.0% - 61.9%
Persons age 45-64 without HS diploma ( • ), 20005 19.9% 8.7% - 36.7%
Persons age 65+ with graduate school education ( • ), 20005 5.5% 1.1% - 18.7%
Persons age 45-64 with graduate school education ( • ), 20005 8.8% 2.4% - 32.4%
Persons age 65+ with limited or no English ( • ), 2000vi 0.5% 0% - 3.8%
Grandparents raising grandchildren age less than 18, 2000vii 79,810 31 – 5,985
Veterans age 65+ (as % of age group), 2000viii 26.8% 16.2% - 37.7%
Distribution by Age1, 2 0-17 18-49 50-64 65-84 85+
Age groups, 2002 24.5% 47.6% 16.0% 10.5% 1.4%
Projection for 2020 23.1% 43.0% 18.8% 13.3% 1.7%
Growth, 2002-2020 124.3% 119.2% 155.5% 166.8% 162.4%
Distribution by Race/
Hispanic Originix White
African
American
Native
American Asian
Hispanic/
Latino
Population age 60+ (as % of age group), 2000 82.0% 16.0% 0.7% 0.5% 0.7%
Population age 45-59 ( “ ), 2000 77.2% 18.9% 1.1% 1.2% 1.7%
Healthy Aging
NC County Range
Persons age 65+ in community with 0 disabilities* (as % of age group), 2000x 54.3% 40.2% - 66.8%
Persons age 65+ in community with 1 disability* ( • ), 200010 20.6% 14.9% - 26.4%
Persons age 65+ in community with 2 or more disabilities* ( • ), 200010 25.1% 17.0% - 34.6%
* The US Census Bureau defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for
persons to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering.”
Medicare beneficiaries immunized for influenza, 2000xi 43.5% 17.2% - 63.5%
Persons age 65+ living alone ( • ), 2000xii 28.3% 21.0% - 34.6%
Long-Term Care and Aging
NC County Range
Men age 65+ in nursing homes, 2000xiii 11,207 0 – 674
Women age 65+ in nursing homes, 200013 33,630 0 – 2,445
Persons age 65+ in nursing homes per 1000, 1999xiv 42.2 25.4 – 89.1
Persons age 65+ in adult care homes per 1000, 199914 36.5 0.0 – 67.8
CAP/DA* clients age 18+ per 1000 Medicaid eligibles, 199914 36.0 8.4 – 200.0
PCS** clients age 18+ per 1000 Medicaid eligibles, 199914 57.7 0.0 – 199.1
Adult day care/health clients age 60+ served per 1000, 199914 1.0 0.0 – 5.0
In-home aides clients, age 60+ per 1000, 199914 9.9 2.0 – 51.5
Medicaid-eligible persons age 65+, SFY 2002xv 152,300 131 – 7,198
Total Medicaid expenditures for persons age 65+, SFY 200216 $1,665,538,382 $1,151,121- $79,755,555
The amount Medicaid spent on home-based care (CAP/DA,
CAP/MR, home health, and PCS) for every $100 spent in nursing
homes for clients age 60+, SFY 2002xvi
$41.5 $6.9 - $278.4
Special Assistance (SA) expenditures for persons age 60+ in adult
care homes, SFY 200216
$90,695,940 $37,987 - $4,035,646
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 29
Economic Security
NC County Range
Median household income for age group 55-64, 1999xvii $42,250 $26,582 - $62,759
Median household income for age group 65-74, 199917 $28,521 $16,335 - $41,540
Median household income for age group 75+, 199917 $19,303 $11,195 - $33,822
Poverty Age 55-64 Age 65-74 Age 75+
Persons below poverty (as % of age group), 1999 (NC) xviii 9.5% 10.5% 16.9%
Persons in 100-199% of poverty ( • ), 1999 (NC)18 12.9% 20.4% 27.1%
Social Security NC County Range
Total Social Security (SS) benefits for beneficiaries age 65+, 2000xix $722 million $0.4 – 50.7 million
SS beneficiaries age 65+ (as % of age group), 2000xx 94.8% 73.1% - 100.0%
Average monthly SS amount received by beneficiaries age 65+, 200019,20 $786 $620 - $889
Medicare/Medicaid
Medicare Part A enrollees age 65+ (as % of all enrollees), 2000xxi 77.0% 65.7% - 86.1%
Medicare/Medicaid dually eligible persons age 65+, 2001xxii 140,535 109 – 6,609
Labor Force
Persons age 45-59 in labor force* (as % of total labor force), 2000xxiii 27.7% 21.7% - 35.8%
Persons age 60-64 in labor force* ( • ), 200023 3.6% 2.5% - 6.9%
Persons age 65+ in labor force* ( • ), 200023 3.5% 2.2% - 8.8%
Persons age 65+ In labor force* (as % of age group), 200023 14.4% 8.9% - 21.1%
Unemployed persons age 65+ (as % of population age 65+ in labor
Force*), 200023
8.3% 0.0% - 40.7%
*Include both employed and job seekers
Senior-Friendly Communities
NC County Range
Homeowners age 45-64 (as % of age group), 2000xxiv 80.3% 70.9% - 89.6%
Homeowners age 65+ ( • ), 200024 82.0% 72.0% - 91.4%
Households with persons age 60+ and without complete plumbing, 2000xxv 8,184 Undisclosed – 343
Home-delivered meals served to persons age 60+ per 1000, 199914 18.6 0 – 58.5
Food Stamps
Food Stamp clients age 60+, SFY 2001xxvi 66,832 66 – 3,893
Total Food Stamp expenditures for clients age 60+, SFY 200126 $39,628,877 $23,963 - $3,177,499
Monthly Food Stamp expenditure per client age 60+, SFY 200126 $49 $35 - $68
Transportation
Householder age 55-64 without car (as % of age group), 2000xxvii 6.0% 1.0% - 15.9%
Householder age 65-74 without car ( • ), 200027 9.0% 4.0% - 22.7%
Householder age 75+ without car ( • ), 200027 21.3% 7.5% - 33.6%
Persons Providing Care Age 18-44 Age 45-64 Age 65+
Persons providing regular care for adults age 60+ (as % of age group),
2000* xxviii
14.5% 23.8% 15.7%
*Only statewide information available at present
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 30
Sources of Information
1
North Carolina State Data Center (2003). County/state population estimates; July 1, 2002; age groups-adults. Retrieved in 6/2003
from http://www.demog.state.nc.us/.
1 North Carolina State Data Center (2003). County/state population projections; April 1, 2020 county age groups; age groups-adults.
Retrieved in 6/2003 from http://www.demog.state.nc.us/.
1 US Bureau of the Census (2003). PCT12. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P2. Urban and rural (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT25. Sex by age by educational attainment for the population 18 years and over (Summary
File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P19. Age by language spoken at home by ability to speak English for the populations 5 years
and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT9. Household relationship by grandparents living with own grandchildren under 18 years by
responsibility for own grandchildren for the population 30 years and over in households (Summary File 3). Retrieved in 6/2003 from
http://www.census.gov/.
1 US Bureau of the Census (2003). P39. Sex by age by armed forces status by veteran status for the population 18 years and over
(Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). P12 A, B, C, D, and H. Sex by age (Summary File 1). Retrieved in 6/2003 from
http://www.census.gov/.
1 US Bureau of the Census (2003). PCT26. Sex by age by types of disability for the civilian noninstitutionalized population 5 years
and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 Medical Review of North Carolina (2003). Influenza immunization data. Retrieved in 2/2003 from
http://www.mrnc.org/MCMED/influenza-results.asp.
1 US Bureau of the Census (2003). P11. Household type (including living alone) by relationship for the population 65 years and over
(Summary File 3). Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT17. Group quarters population by sex by age by group quarters type (Summary File 1).
Retrieved in 6/2003 from http://www.census.gov/.
1 NC Institute of Medicine (2001). A long-term care plan for North Carolina: Final report. Appendix D: Comparisons of availability of
services.
1 NC Division of Medical Assistance (2003). Special tabulations provided for NC Division of Aging in 6/2003.
1 NC Division of Aging (2003). Expenditure data by county for Fiscal Year 2002. Retrieved 6/2003 from
http://www.dhhs.state.nc.us/aging/exp2002/coexp2002.htm.
1 US Bureau of the Census (2003). P56. Median household income in 1999 (dollars) by age of householder (Summary File 3).
Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). PCT50. Age by ratio of income in 1999 to poverty level. (Summary File 3). Retrieved in 6/2003
from http://www.census.gov/.
1 US Social Security Administration (2003). Table 5. Amount of OASDI benefits in current-payment status, by type of benefit, by sex
of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000).
Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html.
1 US Social Security Administration (2003). Table 4. Number of OASDI beneficiaries with benefits in current-payment status, by
type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and
county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html.
1 Medical Review of North Carolina (2003). Medicare Part A Enrollees. Retrieved from in 6/2003
http://www.mrnc.org/NCMED/beneficiary.asp.
1 Medical Review of North Carolina (2003). Dually eligible beneficiaries, 2000. Retrieved from in 6/2003
http://www.mrnc.org/NCMED/beneficiary_dual2001.asp.
1 US Bureau of the Census (2003). PCT35. Age by sex by employment status for the population 16+ years. (Summary File 3).
Retrieved in 6/2003 from http://www.census.gov/.
1 US Bureau of the Census (2003). HCT8. Tenure by age of householder (Summary File 2). Retrieved in 6/2003 from
http://www.census.gov/.
1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging in 6/2003.
1 NC Division of Social Services (2002). Special tabulation as requested by the NC Division of Aging in 9/2002.
1 US Bureau of the Census (2003). P45. Tenure by vehicles available by age of householder (Summary File 3). Retrieved in
6/2003 from http://www.census.gov/.
1 NC Center for Health Statistics (2001). BRFSS-2000 survey results. Retrieved in 7/2003 from
http://www.schs.state.nc.us/SCHS/healthstats/brfss/2000/caretakr.html.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 31
APPENDIX B
North Carolina Study Commission on Aging
Recommendations
to the
2003 North Carolina General Assembly, 2003 Regular Session
Prepared by Staff for the
North Carolina Study Commission on Aging
February 9, 2004
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 33
Recommendation Status Report
North Carolina Study Commission on Aging
RECOMMENDATIONS BILLS
INTRODUCED
RESULTS
RECOMMENDATION 1
The Commission finds that the Community
Alternative Program for Disabled Adults
(CAP/DA) is the cornerstone of community-based
care for older adults and recommends
that the General Assembly fund the program
at a level sufficient to preserve the availability
of community-based services offered through
the program.
N/A
CAP/DA funds for the 02/03 fiscal year are $255,000,000, funds were increased by
approximately $61,000,000 last session.
RECOMMENDATION 2
The Commission recommends that the 2002
Session of the 2001 General Assembly direct
the Department of Health and Human
Services to study ways to establish a group
health insurance purchasing arrangement for
long-term care staff.
H 1559
S 1196
S.L. 2002-180, Sec. 5.2 (SB 98, Sec. 5.2)
Group Health Insurance for Long-Term Care Staff Study
The Department of Health and Human Services, in consultation with the Department of
Insurance, shall study ways to establish a group health insurance purchasing arrangement
for staff, including paraprofessionals, in residential and nonresidential long-term care
facilities and agencies, as described in Recommendation #22 of the Institute of Medicine's
(IOM) Long-Term Care Task Force Final Report of January 2001. The Department shall
report its findings and recommendations to the North Carolina Study Commission on Aging
on or before January 1, 2003.
RECOMMENDATION 3
The Commission recommends that the
General Assembly direct the Department of
Health and Human Services to study ways the
State can coordinate and facilitate public
access to public and private free and discount
prescription drug programs for senior
citizens.
H 1560
S 1199
S.L. 2002-180, Sec. 5.1 (SB 98, Sec. 5.1)
Prescription Drug Access/Coordination
The Department of Health and Human Services shall study ways the State can coordinate
and facilitate public access to public and private free and discount prescription drug
programs for senior citizens. In undertaking this study, the Department shall consider the
coordination and facilitation methods being implemented by other states. On or before
January 1, 2003, the Department shall report its findings and recommendations to the North
Carolina Study Commission on Aging. The report shall include the following:
(1) A description of the various coordination and facilitation methods considered.
(2) A description of the coordination and facilitation methods of other states.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 34
(3) A recommendation as to the best way to coordinate and facilitate access in this
State, which shall include the reasons for the recommendation, a fiscal analysis of
the cost of the recommendation, and whether any legislation is necessary to
implement the recommendation.
RECOMMENDATION 4
The Commission recommends the General
Assembly establish a Legislative Study
Commission on State Guardianship Laws.
H 246
S 179
No action taken on this issue.
RECOMMENDATION 5
The Commission recommends the General
Assembly pursue ways in which national
criminal record checks may be obtained and
reviewed by long-term care facilities to
effectuate State policy and to protect facility
residents.
H 1561
S 1264
S.L. 2002-180, Sec. 2.1A (SB 98, Sec. 2.1A)
Study Issues Related to Criminal History Record Checks of Employees of Long-Term
Care Providers
The Legislative Research Commission may study how federal law affects the distribution of
national criminal history record check information requested for nursing homes, home care
agencies, adult care homes, assisted living facilities, and area mental health, developmental
disabilities, and substance abuse services authorities, and the problems federal restrictions
pose for effective and efficient implementation of State-required criminal record checks.
The study may include the following:
(1) Ways in which national record checks may be obtained and reviewed for these
facilities to effectuate State policies and protections of facility residents, and the
advantages, disadvantages, and costs of various approaches to implementation.
(2) A review of ways in which national record checks are obtained by the Division of
Child Development, Department of Health and Human Services, and other State
agencies, and related costs to the State.
(3) Solutions adopted by other states to effectively and efficiently implement criminal
record check requirements, including costs to the State in implementing these
solutions.
(4) Other issues relevant to State requirements for criminal history record checks in
long-term care facilities.
For each of the topics the Legislative Research Commission decides to study, the
Commission may report its findings, together with any recommended legislation, to the
2003 General Assembly.
Summary of
Substantive Legislation
Related to Aging
North Carolina General Assembly
2003 Session
Prepared by Staff for the:
North Carolina Study Commission on Aging
February 10, 2004
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 36
Enacted Legislation
Continuing Care Retirement/Technical Changes
S.L. 2003-193 (HB 253) makes various technical changes to the statutes that regulate continuing
care retirement communities (CCRCs). These facilities provide housing and health-related services either
for life or for a period in excess of one year. CCRCs provide independent living and also offer nursing
home or adult care home level of care. Because CCRCs include contractual requirements where, for
certain fees, the facility agrees to provide health care coverage over a given period of time, they are
considered an insurance product and are regulated by the Department of Insurance under Article 64 of
Chapter 58.
The act makes the following changes to the statutes:
· Repeals an unused, and likely unusable, provision allowing for a continuing care retirement
facility that is accredited under a process approved by the Commissioner to be issued a
license based on that accreditation.
· Replaces the word "facility" with "provider" to clarify that it is the provider that operates the
facility that is responsible for meeting the various statutory requirements.
· Clarifies language governing operating reserves for continuing care retirement facilities and
providers, including:
1. Changing the wording to reflect the fact that a provider is to calculate and maintain a
separate operating reserve for each continuing care facility operated by the provider.
2. Changing the words "annual statement" to "disclosure statement."
3. Changing the words "invested cash" to "cash equivalents."
· Makes the following changes governing the rights of residents of continuing care retirement
facilities to organize:
4. Changes "registered under this Article" to "operated by a provider licensed under this
Article" in G.S. 58-64-40(a). No entity is "registered" under G.S. 58-64.
5. Makes gender neutral corrections.
6. Clarifies that the governing body of a provider must hold semi-annual meetings with the
residents of each facility operated by the provider.
· Makes various changes governing supervision, rehabilitation and liquidation of continuing
care retirement providers including:
7. Replacing the word "projected" with "forecasted".
8. Amending the statute as necessary to accommodate the fact that a provider can own or
operate more than one facility.
· Amends the provision on receiverships, to reflect the fact that the Commissioner would be
appointed as receiver for a provider not a facility.
· Replaces the word "agreements" with "contracts" for consistency of wording within Article
64.
· Removes unnecessary language to conform with the removal of the "accredited facility"
provision.
· Amends the provision, governing civil liability, to:
9. Remove the misleading words "facility, or person violating this Article" because the
provider is the entity entering into a contract for continuing care, not the facility or other
person.
10. Remove the words "or person liable" because the provider is the only entity that is
required to deliver a disclosure statement to the contracting party.
11. Remove the words "facility, or person" since payment is made to the provider, and the
provider is the entity responsible for the dissemination of the disclosure statement.
This act became effective June 12, 2003. (DJ)
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 37
Senior Cares Program Administration
S.L. 2003-284, Sec. 10.5 (HB 397, Sec. 10.5) provides that the Department of Health and Human
Services may administer the "Senior Cares" prescription drug access program approved by the Health and
Wellness Trust Fund Commission and funded from the Health and Wellness Trust Fund.
This section became effective July 1, 2003. (TM)
Effective Date of Long-Term Care Criminal Record Checks for
Employment Positions
S.L. 2003-284, Sec. 10.8E (HB 397, Sec. 10.8E) continues the suspension of the requirements of
G.S. 131E-265 for nursing homes and G.S. 131D-2 for adult care homes to conduct national criminal
history checks for certain employees until January 1, 2005. These requirements were also suspended
during the last biennium.
This section became effective July 1, 2003. (DJ)
Implement a Pilot Project for Long-Term Care Community Service
Coordination
S.L. 2003-284, Sec. 10.8F (HB 397, Sec. 10.8F) requires the Department of Health and Human
Services to implement a communications and coordination initiative to support local coordination of long-
term care, and to pilot the establishment of local lead agencies to facilitate the long-term care
coordination process at the county or regional level. The initiative must eliminate fragmentation and
barriers to information and services; provide a seamless connection among State agencies and local
entities, regardless of funding sources; and allow consumers to efficiently and effectively navigate among
long-term care services. For those counties that voluntarily participate, the local long-term care
coordination initiative must aid in the development of core services, coordinate local services, and
streamline access to services. The Department of Health and Human Services must submit an interim
report on the pilot project for local long-term care coordination to the North Carolina Study Commission
on Aging by October 1, 2004 and a final report by October 1, 2005.
The Institute of Medicine Long-Term Care Task Force found that "long-term care services are
often fragmented, duplicative, complex, and not consumer-friendly and that many counties lack needed
core long-term care services." In response to this finding, and a report presented in accordance with S.L.
2001-491, Part XXII, the North Carolina Study Commission on Aging's 2003 report to the General
Assembly and the Governor made a recommendation that the General Assembly fund a pilot project on
long-term care local lead agencies. This provision is in response to that recommendation.
This section became effective July 1, 2003. (TM)
Medicare Enrollment Required
S.L. 2003-284, Sec. 10.27 (HB 397, Sec. 10.27) directs the Department of Health and Human
Services to require Medicaid recipients who qualify for Medicare to enroll in Medicare in order to pay
medical expenses that qualify for payment under Medicare Part B. Medicare is the federally sponsored
health insurance program for persons aged 65 or older and for certain disabled persons under age 65.
Medicare Part B pays for doctors' services, outpatient hospital care, and some other medical services that
Part A does not cover, such as the services of physical and occupational therapists, and some home
health care. In order to obtain coverage under Medicare Part B, an eligible person must pay a premium.
Requiring eligible persons to enroll in Medicare will shift health care costs from the Medicaid program
(which is paid in part with State and local funds) to the Medicare program (which is paid entirely with
federal funds).
This section became effective July 1, 2003. (DJ)
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 38
Medicaid Assessment Program for Skilled Nursing Facilities
S.L. 2003-284, Sec. 10.28 (HB 397, Sec. 10.28) directs the Secretary of Health and Human
Services to implement a Medicaid assessment program for skilled nursing facilities effective October 1,
2003. The assessment program applies to skilled nursing facilities licensed under Chapter 131E of the
General Statutes and must be imposed in a manner consistent with federal regulations under 42 C.F.R.
Part 433, Subpart B. Funds realized from assessments imposed shall:
· Be used only to draw down federal Medicaid matching funds for implementing the new
reimbursement plan for nursing homes and for increasing nursing facility rates in accordance
with the plan,
· Be used to pay 100% of the nonfederal share for the new reimbursement plan for nursing
homes; and
· Not be used to supplant State funds appropriated for nursing facility services.
This section became effective July 1, 2003. (TM)
Rename North Carolina Heart Disease and Stroke Prevention Task
Force
S.L. 2003-284, Sec. 10.33B (HB 397, Sec. 10.33B) renames the North Carolina Heart Disease and
Stroke Prevention Task Force. The new name is the Justus-Warren Heart Disease and Stroke Prevention
Task Force.
This section became effective July 1, 2003. (SA)
Senior Center Outreach
S.L. 2003-284, Sec. 10.42 (HB 397, Sec. 10.42) provides that the funds appropriated to the
Department of Health and Human Services, Division of Aging, for the 2003-2005 fiscal biennium, shall be
allocated by October 1 of each fiscal year and used by the Division of Aging to enhance senior center
programs in the following ways:
· To expand the outreach capacity of senior centers to reach unserved or underserved areas;
or
· To provide start-up funds for new senior centers. However, prior to funds being allocated for
start-up funds for a new senior center, the county commissioners of the county in which the
new center will be located shall:
12. Formally endorse the need for such a center;
13. Formally agree on the sponsoring agency for the center; and
14. Make a formal commitment to use local funds to support the ongoing operation of the
center.
Additionally, State funding shall not exceed 75% of reimbursable costs.
This section became effective July 1, 2003. (TM)
Adult Care Home Model for Community-Based Services
S.L. 2003-284, Sec. 10.43 (HB 397, Sec. 10.43) requires the Department of Health and Human
Services to develop a model project for delivering community-based mental health, developmental
disabilities, and substance abuse housing and services through adult care homes that have excess
capacity. The model must be designed for implementation on a pilot basis and address the following:
· Services that will be provided by the facility or under contract with the facility, including
assistance with daily medication.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 39
· Access of clients to mental health, developmental disabilities, and substance abuse services
provided in the community, including transportation to services outside of the client's
residence in the adult care home facility.
· Physical plant additions or changes necessary to provide for independent living of residents.
· Methods for assuring quality of services, resident safety, and cost-effectiveness.
· Consistency with the Department's Olmstead plan, other policies on community-integration,
and disability plans adopted by the State.
The Department must submit a final report on the development of the model to the Senate
Appropriations Committee on Health and Human Services, the House of Representatives Appropriations
Subcommittee on Health and Human Services, and the Fiscal Research Division on or before March 1,
2004. The report shall address the following:
· Proposed time and location for implementation of the pilot.
· Proposed number of residents to be placed and services to be provided directly by the facility
or under contract with the facility.
· Method for evaluating the pilot, including services provided, on a regular basis.
· A description of the living environment for each resident and a comparison of how the living
environment compares to that of other residents in the adult care home.
· Changes to State law necessary to implement the pilot.
· Projected cost to the State for pilot and statewide implementation.
This section provides that the development of this model is in response to the State policy to
provide appropriate services to clients in the least restrictive and most appropriate environment and with
the United States Supreme Court Decision in Olmstead vs. L.C. & E.W.
This section became effective July 1, 2003. (TM)
Special Assistance In-Home Program
S.L. 2003-284, Sec. 10.51 (HB 397, Sec. 10.51) allows the Department of Health and Human
Services to use funds from the existing State-County Special Assistance for Adults budget to provide
Special Assistance payments to eligible individuals with in-home living arrangements. These payments
may be made for up to 800 individuals during the 2003-2004 fiscal year and the 2004-2005 fiscal year.
The standard monthly payment to individuals enrolled in the Special Assistance in-home program shall be
50% of the monthly payment the individual would receive, if the individual resided in an adult care home
and qualified for Special Assistance, except if a lesser payment amount is appropriate for the individual as
determined by the local case manager. For State fiscal year 2003-2004, qualified individuals shall not
receive payments at rates less than they would have been eligible to receive in State fiscal year
2002-2003. The Department must implement Special Assistance in-home eligibility policies and
procedures to assure that in-home program participants are those individuals who need and, but for the
in-home program, would seek placement in an adult care home facility; and shall include the use of a
functional assessment. This in-home option must be available to all counties on a voluntary basis; and to
the maximum extent possible, the Department shall consider geographic balance in the dispersion of
payments to individuals across the State.
The Department is required to report on or before January 1, 2004, and on or before January 1,
2005, to the cochairs of the House of Representatives Appropriations Committee, the House of
Representatives Appropriations Subcommittee on Health and Human Services, the cochairs of the Senate
Appropriations Committee, and the cochairs of the Senate Appropriations Committee on Health and
Human Services. This report shall include the following information:
· A description of cost savings that result from allowing individuals eligible for State-County
Special Assistance the option of remaining in the home.
· A complete fiscal analysis of the in-home option to include all federal, State, and local funds
expended.
· How much case management is needed and which types of individuals are most in need of
case management.
· The geographic location of individuals receiving payments under this section.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 40
· A description of the services purchased with these payments.
· A description of the income levels of individuals who receive payments under this section and
the impact on the Medicaid program.
· Findings and recommendations as to the feasibility of continuing or expanding the in-home
program.
· The level and quantity of services (including personal care services) provided to the
demonstration project participants compared to the level and quantity of services for
residents in adult care homes.
Additionally, the Department shall incorporate data collection tools designed to compare quality
of life among institutionalized versus noninstitutionalized populations (i.e., an individual's perception of
his or her own health and well-being, years of healthy life, and activity limitations). To the extent national
standards are available, the Department shall utilize those standards. These provisions are based on
recommendations from the North Carolina Study Commission on Aging.
This section became effective July 1, 2003. (TM)
State/County Special Assistance Transfer of Assets
S.L. 2003-284, Sec. 10.53 (HB 397, Sec. 10.53) codifies the provision adopted in last year's
budget providing that Supplemental Security Income (SSI) policy concerning transfer of assets and estate
recovery applies to applicants for State-county Special Assistance and repeals current codified law on the
issue. The provision also requires the Department of Health and Human Services to continue reviewing
whether policy for State-county Special Assistance should be changed to permit an assisted living facility
to accept from a family member of a resident who qualifies for State-county Special Assistance payment
for the difference in the monthly rate for room, board, and services available. The Department must
report its activities on this policy review by March 1, 2004 to the Senate Appropriations Committee on
Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and
Human Services, and the Fiscal Research Division.
This section became effective July 1, 2003. (DJ)
Social Services Commission Rules on Rate-Setting For Adult Day
Centers and Adult Day Health Centers
S.L. 2003-284, Sec. 10.58 (HB 397, Sec. 10.58) provides that the Social Services Commission
shall consider adopting rules increasing the rates for adult day centers and adult day health centers and
that any rate increase shall be implemented within existing funds.
This section became effective July 1, 2003. (TM)
Nursing Home/Medication Errors
S.L. 2003-393 (SB 1016) requires every nursing home to establish a medication management
advisory committee to advise the quality assurance committee on quality of care issues related to
pharmaceutical and medication management and use in the nursing home. The Advisory Committee will
have the following duties:
· Assess the facility's pharmaceutical management system and practices and identify areas at
high risk for medication-related errors.
· Review the facility's pharmaceutical management goals and ensure these goals are being
met.
· Review, investigate, and respond to facility incident reports and resident grievances.
· Identify goals and recommendations for the implementation of best practices.
· Develop recommendations for the establishment of a mandatory, nonpunitive, confidential
reporting system.
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 41
· Develop specifications for drug dispensing and administration documentation procedures to
ensure compliance with federal and State law, including the NC Nursing Practice Act.
· Develop specifications for self-administration of drugs by qualified patients in accordance
with law.
As part of its requirement to minimize risk of medication-related error, the act requires every
nursing home quality assurance committee to undertake the following:
· Educate and make the patient and the patient's family members aware of all the medications
the patient is using.
· Increase prescription legibility.
· Minimize confusion in prescription drug labeling and packaging.
· Develop a confidential and nonpunitive process for internal reporting of actual and potential
medication-related errors.
· To the extent practicable, implement proven medication safety practices.
· Educate facility staff engaged in medication administration.
· Implement a system to accurately identify recipients before any drug is administered.
· Implement policies and procedures designed to improve accuracy in medication
administration and in documentation.
· Implement policies and procedures for the self-administration of medication.
· Investigate and analyze the frequency and root causes of general categories and specific
types of actual or potential medication-related errors.
· Develop recommendations for plans of action to correct identified deficiencies in the facility's
pharmaceutical management practices.
The act also requires nursing home to provide a minimum of one hour of education and training
in the prevention of actual or potential medication-related errors for all nonphysician personnel involved
in direct patient care.
A new statute enacted in this act requires consultant pharmacists of nursing homes to undertake
certain drug regimen reviews, make reports concerning drug irregularities, drug product defects and
adverse drug reactions, ensure proper documentation of allergies and adverse effects, and ensure that
drugs that are not specifically limited as to duration of use or number of doses are controlled by
automatic stop orders.
Finally, the act requires the Secretary of Health and Human Services to contract with a public or
private entity to develop and implement a Medication Error Quality Initiative. As part of the Initiative,
each nursing home must report annually on the nursing home's medication-related errors. The report
submitted by each nursing home would not contain information that would identify the patient, individual
reporting the error, or other persons involved in the occurrence. The contracting entity would analyze
the reports to determine trends in the incidence of medication-related errors in nursing homes.
Information released to the contractor would retain its confidentiality and would not be subject to
discovery or use in any civil action as provided under the act.
This act becomes effective January 1, 2004. (DJ)
Audit of CAP/DA Programs by State Auditor
S.L. 2003-284, Sec. 10.29B (HB 397, Sec. 10.29B) directs the State Auditor to perform an audit
of the Community Alternatives Program for Disabled Adults (CAP/DA), provided that State funds are
appropriated for this purpose. The audit shall build upon the results of the study conducted by the North
Carolina Institute of Medicine, in accordance with Section 10.16(c) of S.L. 2002-126, and provide
information necessary to determine whether CAP/DA is operating within waiver guidelines and program
goals. The State Auditor shall report the results of the audit to the North Carolina Study Commission on
Aging by January 1, 2004.
This section also directs the Department of Health and Human Services to review, on a pilot
basis, a selected number of CAP/DA programs to determine compliance with eligibility requirements for
the program. Additionally, the Department shall continue to examine aspects of CAP/DA including: the
current assessment process; an analysis of per-client costs in CAP/DA to per-client costs in nursing
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 42
homes and adult care homes; per-participant costs for the State-County In-Home Program; an analysis of
per-person costs for personal care services through Medicaid; the monitoring of quality of care for
CAP/DA clients; the current waiting list procedures. The Department is required to make a report of its
findings to the North Carolina Study Commission on Aging by January 1, 2004.
This section became effective July 1, 2003. (TM)
Staff Contributing to this publication: Sandra Alley (SA), Dianna Jessup (DJ), and Theresa Matula (TM).
North Carolina Study Commission on Aging
Report to the Governor and the 2003 Session of the 2003 General Assembly
43
Studies and Reports Related to Aging
Study/Report Entities Involved Reporting Date Reference
Report on the pilot project for local long-term care
coordination.
DHHS to Aging Study
Commission
Interim report
10/1/04
Final report 10/1/05
S.L. 2003-284 (HB
397), Sec. 10.8.F.(b)
Report on examination of CAP/DA that includes certain
cost comparisons
DHHS to Aging Study
Commission
1/1/04 S.L. 2003-284 (HB
397), Sec. 10.29B.
Report on development of the adult care home model for
community-based services
DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB
397), Sec. 10.43.(b)
Report on the Special Assistance In-Home Demonstration
Program
DHHS to HHS 1/1/04 and 1/1/05 S.L. 2003-284 (HB
397), Sec. 10.51(b)
DHHS to review whether policy for Special Assistance
should be changed to permit an assisted living facility to
accept from a family member of a resident who qualifies
for the program payment for the difference in the monthly
rate.
DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB
397), Sec. 10.53(c)
DHHS to review activities and costs related to the
provision of care in adult care homes and determine what
costs may be considered to properly maximize allowable
reimbursement available through Medicaid and may
transfer funds from DSS to DMA to draw down federal
Medicaid funds.
DHHS to HHS and FRD As funds are
transferred and rates
are modified
Abbreviations:
DHHS: the Department of Health & Human Services
FRD: Fiscal Research Division
HHS: House of Representatives Appropriations Subcommittee on Health and Human Services & Senate Appropriations Committee on Health and Human Services
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly 44
APPENDIX C
North Carolina Study Commission on Aging
Report to the Governor and the 2004 Session of the 2003 General Assembly
45
Overview of Aging Services &
State Aging Plan
N.C.G.S. 143B-181.1A
prepared by
Division of Aging, N.C. Department of
Health and Human Services
for the
Study Commission on Aging
NC Division of Aging 2
The Aging of North Carolina—
General Organization of Plan
¡ Aging NC
¡ Healthy Aging
¡ Long-Term Care and Aging
¡ Economic Security
¡ Senior-Friendly Communities
�� Priorities of Senior Advocates
¡ State Agencies Major Activities and
Future Directions
NC Division of Aging 3
Actual and Projected Population Age 65 and Older,
North Carolina, 1940 t